Participant Guide - TMHP Workshop/2009_DME...DME Workshop Participant Guide Services for Children If...

v 2009 0223

Durable Medical Equipment Workshop

Participant Guide

2 CPT only copyright 2008American Medical Association. All rights reserved. — v 2009 0223

DME Workshop Participant Guide

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v 2009 0223 — CPT only copyright 2008American Medical Association. All rights reserved. 3


Contents

What is DME? ....................................................................................................................... 6

Medicaid Benefits .................................................................................................................. 7

CSHCN Services Program Benefits ..................................................................................... 12

Eligibility ............................................................................................................................. 16Eligibility Verification ........................................................................................................ 16Medicaid – Service Eligibility Criteria ................................................................................ 17CSHCN Services Program Eligibility Criteria .................................................................... 17Eligibility Inquiry Volumes ................................................................................................ 21Verifying Client Eligibility Using TexMedConnect ............................................................ 22Limitations to Medicaid Client Eligibility .......................................................................... 23Other Claims Filing Factors ............................................................................................... 23Private Pay Policies ............................................................................................................. 24

Prior Authorization ............................................................................................................. 25Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form ............ 25CSHCN Services Program – Services Requiring Authorization and Prior Authorization .... 26CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME) Form ..................................................... 27Accessing the TMHP Website and Prior Authorization Submission Form .......................... 29Search for an Existing Prior Authorization and Review Status ............................................ 31

Verification of Receipt ......................................................................................................... 33DME Certification and Receipt Form ................................................................................ 33CSHCN Services Program Documentation of Receipt ....................................................... 35



Claims Filing........................................................................................................................ 36Filing a Claim .................................................................................................................... 36Claim Filing Instructions for TexMedConnect ................................................................... 36Saving a Claim ................................................................................................................... 38Advantages of Electronic Services ....................................................................................... 39CMS-1500 Claim Form ..................................................................................................... 40Tips on Expediting Paper Claims ....................................................................................... 41Medicare Crossover Claims ................................................................................................ 42Medicare Crossover Reimbursement of Part B.................................................................... 42Clients Eligible for Medicaid and CSHCN Services Program Benefits ............................... 43Filing Deadlines ................................................................................................................. 44Remittance and Status (R&S) Report Example .................................................................. 44Electronic Remittance and Status (ER&S) Agreement ....................................................... 45

Appeals ................................................................................................................................. 46Appeal Methods ................................................................................................................ 46Electronic Appeals .............................................................................................................. 47Automated Inquiry System Appeals.................................................................................... 48Automated Inquiry System Automated Appeals Guide ....................................................... 48Paper Appeals ..................................................................................................................... 49

Waste, Abuse, and Fraud ..................................................................................................... 50Definitions ......................................................................................................................... 50Most Frequently Identified Fraudulent Practices ................................................................ 50Identifying Waste, Abuse, and Fraud .................................................................................. 50Reporting Waste, Abuse, and Fraud ................................................................................... 51

Resources ............................................................................................................................. 52Instructions for Using the TMHP Website ......................................................................... 52TMHP Telephone and Fax Communication ...................................................................... 55CSHCN Services Program Telephone and Fax Communication ........................................ 55Written Communication With TMHP .............................................................................. 56Written Communication with CSHCN Services Program ................................................. 57EOB Codes - Top Reasons for Claim Denial ...................................................................... 58Common Claim Denial Codes ........................................................................................... 59Acronyms ........................................................................................................................... 60

Provider Enrollment ............................................................................................................ 62Medicaid Enrollment ......................................................................................................... 62CSHCN Services Program Enrollment .............................................................................. 63



What is DME?

DME stands for Durable Medical Equipment.

Medicaid

Texas Medicaid defines DME as: Medical equipment or appliances that are manufactured to withstand repeated use, ordered by a physician for use in the home, and required to correct or ame-liorate a client’s disability, condition, or illness.1

CSHCN Services Program

The CSHCN Services Program defines custom DME as medical equipment that is made or modified specifically to address the individual client’s needs. Noncustom DME is defined as medical equipment that can be obtained from a store or a mail-order company and does not require adaptation or modification for the client’s use.2

Providers must be enrolled as a custom DME provider to provide custom equipment. Enroll-ment instructions for custom DME are listed under “CSHCN Provider Enrollment” in this workbook.

There is no single authority, such as a federal agency, that confers the official status of “DME” on any device or product, therefore, HHSC and DSHS retain the right to determine which DME devices or products are benefits of Texas Medicaid and the CSHCN Services Program.

DME benefits must have either a well-established history of efficacy or, in the case of novel or unique equipment, valid, peer-reviewed evidence that the equipment corrects or ameliorates a covered medical condition or functional disability.

DME costs are payable under Medicare Part B. The client must therefore be enrolled in Part B and Medicare payment is subject to the Part B deductible and co-insurance requirements. Medicare generally pays 80 percent of the fee schedule amount for an item and related supplies or services, and the beneficiary is responsible for the remaining 20 percent.

1 Source: 2009 Texas Medicaid Provider Procedures Manual, Section 24.5.15

2 Source: 2008 CSHCN Services Program Provider Manual, Section 14.3.1



Medicaid Benefits

Incontinence Supplies and Equipment 1

Incontinence supplies and DME are defined as disposable supplies such as diapers, briefs, pull-ons, liners, wipes, underpads, skin sealants, protectants, moisturizers, ointments, and DME that are used by clients 4 years of age and older who have a medical condition that results in chronic impairment of urination and/or stooling, or that renders them unable to ambulate safely to the bathroom (with or without mobility aids).

Incontinence Equipment Examples

Urinals and bed pans (purchase-only)•Commode chairs•Foot rests•

Services for Children

Texas Health Steps (THSteps)-eligible clients who qualify for medically necessary services be-yond the limits of this home health benefit will receive those services through THSteps-CCP. This could include:

Skin sealants, protectants, moisturizers, and ointments•External urinary collection•

Diabetic Supplies and Equipment2

Diabetic supplies and equipment are a benefit through Home Health Services.

Diabetic Supply/Equipment Examples

Blood testing supplies: Blood glucose test/reagent strips and home glucose disposable •monitors with strips.Blood glucose monitors•Insulin pumps•

Services for children

THSteps-eligible clients who qualify for medically necessary services beyond the limits of this home health benefit will receive those services through THSteps-CCP.





Enteral Nutritional Products and Supplies1

Enternal nutritional products are those food products that are included in and enteral treat-ment protocol. They serve as a therapeutic agent for health maintenance and are required to treat an indentified medical condition. Nutritional products, supplies and equipment may be provided in the home under Home Health Services.

Enteral Nutrition Examples

Gravity Bags•

Feeding Pumps•

Gastrostomy Kits•

Enteral Feeding Pumps With Alarms•

Enteral Feeding Suringes (Without Needles)•

Irrigation Suringes•

Nutritional supply Examples•

Nutritional Formulas•

Vitamins•

Food Thickeners•


Medical nutritional products for clients who are birth through 20 years of age are available only through THSteps-CCP. Medical nutritional products may be approved for clients who are THSteps-CCP-eligible, birth through 20 years of age, and have specialized nutritional require-ments. Medical nutritional products must be prescribed by a physician and be medically neces-sary. Federal Financial Participation (FFP) for the medical nutritional product must also be available.

Donor human milk is a benefit of THSteps-CCP for eligible THSteps clients who are birth through 11 months of age and meet certain criteria.

Hospital Beds and Equipment2

Hospital beds are defined as medical beds that are used by a client who has a medical condition that requires positioning the body in ways that are not feasible with an ordinary bed. Hospital beds and related equipment are considered for reimbursement for the diagnosis or treatment of illness or injury or to improve the function of a malformed body member.

Hospital Equipment Examples

Trapeze Bar•

An Over-Bed Table•

Pressure-Reducing Support Mattresses•

Decubitus Care Accessories•






If the client is not eligible for home health services, hospital beds may be provided under THSteps-CCP for clients 20 years of age or younger.

Home Health Services may cover reflux slings or wedges for clients who are 11 months of age or younger. These may be used as positioning devices for infants who require elevation after feedings when prescribed by a physician as medically necessary and appropriate. Reflux slings, wedges, or covers require prior authorization.

Respiratory Equipment and Supplies1

Respiratory equipment is defined as any device that assists a client’s ventilation. Respiratory equipment and supplies may be provided in the home under Home Health Services.

Respirator Equipment/Supply Examples

Intermittent positive pressure breathing device•

Electrical percussor•

High-frequency chest wall compression system (HFCWCS)•

Cough-stimulating device (Cofflator)•

Continuous positive airway pressure (CPAP) system•

Bi-level positive airway pressure (BiPAP) system without backup (such as BiPAP S)•

Bi-level positive airway pressure system with backup (such as BiPAP ST)•

All home mechanical ventilation equipment•

Home oxygen systems•

Oral device/appliance•


Respiratory equipment and related supplies that are not considered a benefit under Home Health Services may be considered for reimbursement through THSteps-CCP for clients 20 years of age or younger, who are THSteps-CCP eligible

Augmentative Communication Device 2

An ACD system, also known as an Augmentative and Alternative Communication (AAC) device system, allows a client to overcome the disabling effects of sever communication impair-ment by representation of vocabulary or ideas and expression of messages and enables the client to meet their functional speaking needs.

ACD Equipment Examples

Digitized Speech Device•

Synthesized Speech Device •





Bath and Bathroom Equipment1

Bath and bathroom equipment is DME that is included in a treatment protocol, serves as a therapeutic agent for life and health maintenance, and is required to treat an indentified medi-cal condition. Bath and bathroom equipment may be considered for reimbursement for those clients who have physical limitations that do not allow for bathing, showering, or bathroom use.

Bath and Bathroom Equipment Examples

Hand-held shower/shower wands •

Bath/shower chairs, Tub stool/bench, tube transfer bench•

Non-fixed toilet rails. Bathtub rail attachment, and raised toilet seat•

Portable Sitz bath•

Bath lifts•


If the client is not eligible for home health services, blood pressure devices may be provided un-der THSteps-CCP for clients 20 years of age or younger.

Rental of electronic blood pressure devices may be prior authorized through THSteps-CCP for clients 11 months of age or younger.

Intravenous (IV) Therapy Equipment and Supplies2

Examples

Peripheral IV lines•

Central IV lines•

Central venous line•

Implantable ports•

Phototherapy Devices3

Phototherapy devices for use in the home may be a benefit of Texas Medicaid for lower risk infants. Medium to high risk infants as defined by the American Academy of Pediatrics (AAP) should be considered for other more extensive treatment in an inpatient setting.

A home phototherapy device uses light exposure with white, blue, or green lights to increase bilirubin excretion in the infant with elevated bilirubin levels.

Home phototherapy services include parent/guardian education and obtaining laboratory specimens. Laboratories performing analysis of laboratory specimens may bill according to established procedures.



3 Source: February 2009 Medicaid Medical Policy Manual, “Phototherapy Devices - Home Health”



Retroactive Eligibility

Newborn babies may not have a Medicaid number at the time that services are ordered by the physician and provided by the supplier. In these cases, authorization may be given retroactively for services rendered between the start date and the date that the client’s Medicaid number be-comes available. The provider is responsible for finding out the effective dates of client eligibil-ity. The provider has 95 days from the date on which the client’s Medicaid number becomes available to obtain authorization for services that were already rendered.

Mobility Aids1

Examples

Canes, crutches, and walkers•

Wheelchairs (manual, custom, and powered)•

Scooters•

Lifts (client, hydraulic, and electric)•

Standers•

Gait Trainers•


A mobility aid for a client 20 years of age or younger is medically necessary when it is required to correct or ameliorate a disability or physical illness or condition. THSteps-eligible clients who have a medical need for services beyond the limits of this Home Health Services benefit may be considered under THSteps-CCP.

Wound Care Supplies and Systems2

Wound care supplies and systems are designed to assist in healing of wounds in conjunction with an individualized wound care therapy regimen prescribed by a physician. A wound care system includes a medical device and its component supplies designed to assist in healing of wounds unresponsive to conventional wound care therapy.

Wound Care Examples

Thermal wound care system•

Sealed suction wound care system•

Pulsatile jet irrigation system•





CSHCN Services Program Benefits

Expendable Medical Supplies1

The CSHCN Services Program provides benefits for expendable medical supplies for eligible clients. A medical supply is defined as an item necessary to carry out a medical procedure or to maintain the client’s health at home. Most medical supplies are expendable, meaning that they are either not reusable or usable only for a short time and are discarded after use.

Supplies are a benefit only for those clients residing at home. Articles of daily living are not a CSHCN Services Program benefit.

Expendable Medical Supply Examples

Ostomy and catheterization supplies•

Feeding supplies, such as feeding bags for pumps, tubing, syringes, gastrostomy tubes, and •nasogastric tubes.

Dressings•

Diabetic care, such as testing supplies, and lancets•

Hearing aid batteries.•

Incontinence supplies, such as urinary catheters, gloves, lubricants, skin disinfectants, pull-•ups, briefs, and liners.

Miscellaneous supplies used in the treatment of a medical condition.•

Respiratory care supplies, such as tubing, nebulizer supplies, suction catheters, oxygen •masks, nasal cannulas, and supplies for cleansing respiratory equipment.

Diabetic Supplies and Equipment

Insulin Pumps

CSHCN providers may be reimbursed for DME related to the rental of an insulin pump. DME supplies should be listed individually on the claim for reimbursement consideration. If a client requires more than the amounts specified in the CSHCN Services Program Provider Program Manual, and the claim is denied, the provider must submit documentation of medi-cal necessity with the appeal. The external insulin pump may be considered for purchase when specific conditions have been met.




Glucose Monitors

Glucose monitors may be authorized for clients with Type 1 or Type 2 diabetes mellitus. Pro-viders must use the “CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME).” If a blood glucose monitor with features beyond the basic model is preferred, the client’s parent or guardian must pay the difference in the cost. Claims or requests for authorization must be submitted using procedure code J/L-E0607.

Insulin and insulin Syringes

Insulin and insulin syringes provided to CSHCN Services Program clients are reimbursed through the Medicaid Vendor Drug Program.

Medical Foods1

The CSHCN Services Program may cover medical foods for clients with inborn errors of me-tabolism that prohibit them from eating a regular diet. Medical foods are defined as:

Lacking in the compounds which cause complications of the metabolic disorder.•

Not generally available in grocery stores, health food stores, or pharmacies.•

Not used as food by the general population.•

Not foods covered under the Food Stamps program.•

Approved products listed in enrolled providers’ catalogs.•

CSHCN only pays for foods with nutritional value. Foods with nutritional value include, but are not limited to the following: bread, pasta, flours, Jello, soups, and cheese. Foods with minimal nutritional value, including but not limited to, candy, candy covered items, chocolate, chocolate covered items, cookies, cakes, pies, dessert items, chips, onion rings, cookie dough, gum, or cake mixes are not a benefit.

The CSHCN Services Program may reimburse medical nutritional products. Medical nutri-tional products are those nutritional products that serve as a therapeutic agent for life and health and are part of a treatment regimen. The CSHCN Services Program does not cover nutritional products for individuals who can be sustained on an age appropriate diet.

Medical Nutritional Counseling Services

The CSHCN Services Program provides coverage for nutritional assessment and counseling to prevent, treat, or minimize the effects of illness, injury, or other impairments.

Nutrition assessment and counseling services are a benefit of the CSHCN Services Program when:

Prescribed by a physician.•

Documentation supports medical necessity/appropriateness.•

Completed by a CSHCN Services Program-enrolled dietitian licensed by the Texas State •Board of Examiners of Dietitians.

Services are provided in the home or office.•




Hospital Beds1

Manual and electric hospital beds with accessories may be rented if the need is short-term (not to exceed six months). The anticipated rental cost must be less than the purchase price. Docu-mentation of medical necessity must be submitted with the claim.

Examples of short-term needs include:

Post surgery.•

Client’s life expectancy is very limited (six months or less), as certified by the prescribing •physician.

Manual and electric hospital beds with or without mattresses and/or accessories, or the acces-sories themselves may be purchased for the long-term care of clients whose conditions have progressed to the point that they are severely neurologically and/or orthopedically limited, etc. Providers must complete and submit the “CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME).” All requests require medical review for the purchase of electric hospital beds.

Hospital Cribs and Enclosed Beds

Hospital cribs or enclosed beds are considered custom equipment and may be considered for reimbursement if documentation supporting the medical necessity or appropriateness is submitted with the request for prior authorization. Requests for cribs or enclosed beds must be prior authorized and are referred for medical review.

Respiratory Equipment and Supplies2

The CSHCN Services Program may reimburse the rental or purchase of medically necessary and appropriate respiratory equipment. The item must be prescribed by a licensed physician and be a benefit of the CSHCN Services Program.

Equipment may be rented or purchased depending on the cost-effectiveness of the action requested. In general, equipment is purchased if it is needed for more than six months. The CSHCN Services Program purchases only new, unused equipment. Reimbursement of rented equipment includes all supplies, accessories, adjustments, repairs, or replacement parts needed during the rental period.

1 Source: 2008 CSHCN Services Program Provider Manual, Section 14.14




Hygiene Equipment1

Hygiene equipment may be noncustom DME, or it may be custom DME if it is in any way customized to the individual client’s needs. Hygiene equipment should be rented if the need is for short-term use and if renting is more cost-effective. Documentation of the client’s antici-pated independence with the equipment is required for rental and purchase. Additionally, equipment may be authorized for clients who are nonambulatory in order to assist the parents and enhance safety in the care of clients with spina bifida, cerebral palsy, and other paralytic conditions.

Commode Chairs

Level 1: Stationary Commode Chair•

Level 2: Mobile Commode Chair•

Level 3: Custom Commode Chair•

Extra-wide/Heavy Duty Commode Chair•

Replacement Commode Pail or Pan•

Infusion Pumps2

The CSHCN Services Program may reimburse providers for an external ambulatory infusion pump, when it is prescribed by a physician and authorized by the program. Requests must be submitted to the CSHCN Services Program using the “CSHCN Services Program Prior Au-thorization and Authorization Request for Durable Medical Equipment (DME).”

Phototherapy Devices

Phototherapy devices for use in the home are a benefit of the CSHCN for low-risk infants diagnoses. Medium to high-risk infants, as defined by the AAP, should be considered for other, more extensive treatment in an inpatient setting.

Ambulation Aids3

Ambulation aids may be noncustom DME, or they may be custom DME if they are in any way customized to the individual client’s needs. Crutches, walkers, gait/ambulation belts, and canes may be authorized for any condition resulting in limited functional ambulation.

Ambulation Aid Examples

Gait Trainers•

Standers, Prone or Supine•

Travel Chairs•

Wheelchairs•

Adaptive Strollers•






Eligibility

Eligibility Verification1

1 Source: 2009 Texas Medicaid Provider Procedures Manual, Section 4.1.5, and 2008 CSHCN Services Program Provider Manual, Section 2.3

To verify client eligibility, use the following options:

Paper

Verify the client’s Medicaid eligibility using form •H1027 or H3087.

Verify the client’s CSHCN Services Program •eligibility by using the CSHCN Services Program Eligibility Form.

TexMedConnect

Verify electronically through TexMedConnect. •Providers may inquire about a client’s eligibility by electronically submitting the following information for each client:

Medicaid or CSHCN Services Program identi- –fication number, or

One of the following combinations: –

Social Security number and last name –

Social Security number and date of birth –

Last name, first name, and date of birth –

Narrow the search by entering the client’s county code or sex.

Submit verifications in batches limited to 5,000 •inquiries per transmission.

AIS

Contact Medicaid AIS at 1-800-925-9126, •1-512-335-5986, 1-512-335-6033, 1-512-335-6217, or 1-512-345-6476.

Contact TMHP CSHCN Services Program AIS at •1-800-568-2413.

Other

Contact the DSHS-CSHCN Services Program at •1-800-252-8023.

Submit a hard-copy list of clients to TMHP. This •service is only used for clients with eligibility that is difficult to verify. A charge of $15 per hour plus $0.20 per page payable to TMHP applies to this eligibility verification. The list includes names, gender, and dates of birth if the Social Security and Medicaid identification numbers are unavailable. TMHP can check the client’s eligibility manually, verify eligibility, and provide the Medicaid iden-tification numbers. Mail the lists to the following address:

Texas Medicaid & Healthcare Partnership Contact Center

12357-A Riata Trace Parkway Suite 100

Austin, TX 78727



Medicaid – Service Eligibility Criteria1

The Medicaid client must be eligible on the date of service (DOS) and must meet all the fol-lowing requirements to qualify for Home Health Services:

Have a medical need for home health professional services, DME, or supplies that is docu-•mented in the client’s POC and considered a benefit under Home Health Services

Receive services that meet the client’s existing medical needs and can be safely provided in •the client’s home

Receive prior authorization from TMHP for most home health professional services, •DME, or supplies. Certain DME/supplies may be obtained without prior authorization although providers must retain a Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form reviewed, signed, and dated by the treating physician for these clients.

CSHCN Services Program Eligibility Criteria2

The eligibility requirements for the CSHCN Services Program are:

The applicant lives in Texas and is a bona fide resident who, if a minor child, is also the de-•pendent of a bona fide Texas resident. A bona fide resident physically lives in Texas, intends to remain in Texas permanently or indefinitely, maintains living quarters in Texas, does not claim to be a resident of another state or country, and has not come to Texas from another country for the purpose of obtaining medical care.

The applicant must be 20 years of age or younger. •

Persons with the diagnosis of cystic fibrosis are exempt from age limitations. •

The applicant’s family must meet the CSHCN Services Program financial eligibility crite-•ria.

The applicant’s physician or dentist must complete a Physician/Dentist Assessment Form •(PAF), attest the applicant meets the program’s Medical Certification Definition, and pro-vide a diagnosis with a valid ICD-9-CM that meets the medical certification definition.

Financial Eligibility Criteria

Applicants who are 18 years of age or younger and are applying or reapplying for the CSHCN Services Program must also apply to Texas Medicaid, to the Medically Needy Program (MNP), and to teh Children’s Health Insurance Program (CHIP). A written Texas Medicaid and CHIP determination must be sent with the application for the CSHCN Services Program. Applicants who are not citizens or legal residents of the United States, or who are currently enrolled in CHIP or Texas Medicaid, are exempt from this requirement.





Form H3087-S1/April 2007

RETURN SERVICE REQUESTEDDO NOT SEND CLAIMS TO THE ABOVE ADDRESS

Texas Health and Human Services Commission MEDICAID IDENTIFICATION

IDENTIFICACIÓN DE MEDICAID

Date Run BIN BP TP Cat. Case No.

GOOD THROUGH: VÁLIDA HASTA:

ANYONE LISTED BELOW CAN GET MEDICAID SERVICES

You are enrolled in the STAR Program. Your health plan’s name and telephone number are listed under your name. You have a Primary Care Provider (PCP). Call your health plan for your PCP’s name. If you see a reminder under your name, please call your PCP or dentist to schedule a checkup. If you do not see a reminder and are 21 or older, you can get a medical checkup from your PCP once a year. You can also use the STAR Program to get the health care that you need. Questions about the STAR Program?

CADA PERSONA NOMBRADA ABAJO PUEDE RECIBIR SERVICIOS DE MEDICAID

Usted está inscrito en el Programa STAR. El nombre y el teléfono de su plan de salud aparecen debajo de su nombre. Usted tiene un Proveedor de Cuidado Primario (PCP). Llame al plan de salud para averiguar el nombre de su PCP. Si bajo su nombre hay una notificación, llame a su PCP o dentista para hacer una cita para un chequeo. Si no hay una notificación y usted tiene 21 años or más, puede hacerse un chequeo médico con su PCP una vez por año. También puede usar el Programa STAR para recibir los servicios médicos que necesita. ¿Tiene preguntas sobre el Programa STAR?

Please call 1-800-964-2777 for help. READ BACK OF THIS FORM!

Por favor, llame al 1-800-964-2777 para conseguir ayuda. ¡LEA EL DORSO DE LA FORMA!

ID NO. NAME DATEOF BIRTH

SEX

ELIGIBILITYDATE

TPR

MEDICARENO. EY

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AM

EYE

GLAS

SES

HEAR

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AID

DENT

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PRES

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S

MEDI

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SERV

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If you have Medicare, effective January 1, 2006, you are eligible for Medicare Rx and your Medicaid prescription drug

coverage will be limited.

Si tiene Medicare, a partir del 1° de enero de 2006, usted llenará los requisitos de Medicare Rx y se limitará su cobertura de

medicamentos recetados de Medicaid.

P.O. BOX 149030 952-XAUSTIN, TEXAS 78714-9030

07/15/2008 610098 13 13 04 123456789JULY 31, 2008

952-X 123456789 13 13 04 030731 JANE DOE 743 GOLF IRONS LUCAS TX 75002

123456789 JANE DOE 04-02-1964 F 11-01-2006

1 ATFF 01-00001

✔ ✔ ✔ ✔ ✔/ /WELBY MARCUS L MD

Eligibility indicator appears here.

The name and address at the top of the H3087 is for mailing purposes only. The eligible individuals are listed in the table on the lower half of the page. Be careful, as the person to whom the form is mailed is not necessarily eligible for benefits. If you see that person again in the table, then he/she is eligible. If not, that person could be a non-eligible parent or guardian.

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TEXAS DEPARTMENT OF STATE HEALTH SERVICES

PARENT/GUARDIAN NAME STREET ADDRESS CITY, TX ZIPCODE

CSHCN Services Program Eligibility Form

This form may be used for services only between the “valid” dates listed in the box above.

This is your NEW CSHCN Services Program Eligibility Form. If you already have a form, throw away the old one. Take this form with you when you visit CSHCN Services Program providers. Do not loan this form to other people. Service providers can copy the form for their files. If you lose this form, call the CSHCN Services Program Eligibility Section. Whenever you call or write to the CSHCN Services Program, use the case number (Case #) shown on this form.

You must reapply for the CSHCN Services Program every 6 months. Send a new application and all proofs each time you reapply for CSHCN Services Program financial eligibility.

To stay on the CSHCN Services Program after this form runs out you must fill out a new CSHCN Services Program application and send the application to the CSHCN Services Program on or after xx/22/2xxx. However, your application must be received by the CSHCN Services Program not later than xx/03/2xxx. To get a new CSHCN Services Program application, call the CSHCN Services Program at 1-800-252-8023.

Este formulario se puede usar para conseguir servicios solamente durante las fechas válidas (valid) indicadas en la casilla de arriba.

Éste es su NUEVO formulario de elegibilidad para el Programa de Servicios de CSHCN. Si usted ya tiene un formulario, tire el formulario viejo. Lleve este formulario consigo para obtener servicios de los proveedores del Programa de Servicios de CSHCN. No preste este formulario a otras personas. Los proveedores pueden hacer una copia de este formulario para sus archivos. Si usted pierde este formulario, llame al personal de la Sección de Elegibilidad del Programa de Servicios de CSHCN. Siempre y cuando usted llame o escriba al Programa de Servicios de CSHCN, use el número de caso (Case #) que aparece en este formulario.

Usted tiene que presentar una nueva solicitud para el Programa de Servicios de CSHCN cada 6 meses. Mande una nueva solicitud y todos los comprobantes cada vez que usted presente una solicitud para elegibilidad financiera al Programa de Servicios de CSHCN.

Para continuar en el Programa de Servicios de CSHCN después de que termine su elegibilidad, tiene que rellenar una nueva solicitud del Programa de Servicios de CSHCN y mandar la solicitud al Programa de Servicios de CSHCN después del xx/22/2xxx. Sin embargo, el Programa de Servicios de CSHCN tiene que recibir su solicitud al más tardar el xx/03/2xxx. Para obtener una nueva solicitud para el Programa de Servicios de CSHCN, llame al Programa de Servicios de CSHCN al número 1-800-252-8023.

Provider Information

The client named on this form is eligible for CSHCN Services Program benefits for the period indicated. Service providers may duplicate this form for their files. Providers must be enrolled in the CSHCN Services Program. Prior authorization is required for some services. The CSHCN Services Program may revoke eligibility in the event of policy changes, changes in client medical or financial condition, or error. See the CSHCN Services Program Provider Manual for details. For more information, contact the CSHCN Services Program.

Under certain circumstances, the eligibility form MAY NOT be valid at the time you see this client. Please verify client’s eligibility for CSHCN Services Program Benefits by calling CSHCN-AIS at 1-800-568-2413 or the TMHP-CSHCN Contact Center at 1-800-568-2413.

DAVID L. LAKEY, M.D.. COMMISSIONER

P.O. Box 149347 • Austin, Texas 78714-9347 1-888-963-7111 • http://www.dshs.state.tx.us

Children with Special Health Care Needs Services Program Automated Inquiry System (AIS):

1-800-568-2413Phone: 1-800-252-8023 or 512-458-7355

CSHCN Services Program Case # 9-123456-00

Name: CLIENT NAME Birth: 06/05/00 Sex: M Medicaid/InsuranceMedicaid Number: 123456789 Valid xx/01/2xxx thru xx/03/2xxx

SAMPLE



Eligibility Inquiry Volumes

0

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

30,000,000

35,000,000

40,000,000

Volu

me

Electronic/Web Portal AIS Phone

Inquiry Method

Three Month Average Totals

Source –MULTIPLE – Avaya (Phone and AIS data); C21/CMS (Electronic data); Portal data

Report – Custom Queries; Note: Phone volumes are per call with corresponding EV reason codes. There may be up to 10 EVs per call.

The 3-month trend weekly average of eligibility inquiries is:

EDI TexMedConnect AIS Phone Total

36,933,358 1,149,933 12,995 8,737 38,105,023

The weekly volumes of eligibility inquiries are:

Report Week EDI TexMedConnect AIS Phone Total

11/29/2008 35,853,492 631,036 7,105 5,277 36,496,910

11/22/2008 39,335,262 1,085,051 12,707 9,603 40,442,623

11/15/2008 34,626,783 1,042,879 13,473 9,350 35,692,485

11/8/2008 38,759,356 1,197,030 16,662 9,703 39,982,751

11/1/2008 48,267,238 979,338 12,441 9,150 49,268,167

10/25/2008 37,048,171 1,208,666 11,965 8,896 38,277,698

10/18/2008 38,446,070 1,050,904 13,116 8,784 39,518,874

10/11/2008 34,899,844 1,133,457 14,074 9,131 36,056,506

10/4/2008 36,794,887 1,334,812 15,601 10,050 38,155,350

9/27/2008 37,079,329 915,332 13,170 9,289 38,017,120

9/20/2008 27,335,232 2,045,852 13,389 7,475 29,401,948

9/13/2008 34,754,634 1,174,839 12,235 8,141 35,949,849



Verifying Client Eligibility Using TexMedConnect

Go to TMHP.com.1.

Select 2. Verify Client Eligibility from the right navigation panel.

Enter your username and password.3.

Enter the provider NPI/API and the eligibility to and through dates4.

Narrow your search by entering additional information in any of the following combina-5. tions:

Texas Medicaid/CSHCN Services Program ID –

SSN and Last Name –

SSN and DOB –

Last Name, First Name and DOB –

Note: Printed results are considered valid proofs of eligibility. If you perform more than one check, the provider NPI/API on the Eligibility Search page defaults to the most recently used provider number.



Limitations to Medicaid Client Eligibility

Additional and detailed information is available in the Texas Medicaid Provider Procedures Manual.

Emergency:• Client is limited to coverage for an emergency medical condition. Emergency means a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the client’s health in jeopardy, serious impairment of bodily functions, or serious dysfunction of any body organ or part.

Limited:• Client is limited to seeing the provider or pharmacy listed on the Medicaid ID Form (Form H3087). Refer to the current Texas Medicaid Provider Procedures Manual for exceptions. In the event of emergency medical conditions, the Limited restriction does not apply.

QMB:• Qualified Medicare Beneficiary—Texas Medicaid provides coverage of Medicare deductible and coinsurance liabilities. This client is not eligible for regular Texas Medicaid benefits.

MQMB:• Medicaid Qualified Medicare Beneficiary—Texas Medicaid provides regular Medicaid coverage as well as coverage of deductible and coinsurance liabilities within Texas Medicaid reimbursement limitations.

Hospice:• Client waives the right to Texas Medicaid services related to the terminal condi-tion but not to services for conditions unrelated to the terminal condition. The Depart-ment of Aging and Disability Services (DADS) Hospice reimburses the provider for all services related to the treatment of the terminal illnesses. When the services are unrelated to the terminal illness, Medicaid (TMHP) reimburses its providers directly.

PE:• Presumptive Eligibility—Client is eligible only for medically necessary outpatient ser-vices and family planning services. Labor, delivery, and inpatient medical services are not covered.

Women’s Health Program:• (WHP)—Participants receive a limited family planning benefit that supports the goal of the program to expand access to family planning services that reduce unintended pregnancies in the eligible population. WHP participants do not have access to full Medicaid covereage. Not all Texas Medicaid family planning benefits are pay-able.

Other Claims Filing Factors

TPR:• Third-Party Resources (TPR)—Before filing with Texas Medicaid, claims must be filed with a third party resource: either (P) private insurance or (M) Medicare.

Texas Medicaid Managed Care Programs:• The client is enrolled in the Texas Medicaid Managed Care Program and has selected or has been assigned to one of several managed care programs. Check with the client’s managed care organization to verify eligibility by calling the plan’s telephone number that is listed on Form H3087.



Private Pay Policies

When to Use the Private Pay Agreement

When the client’s eligibility cannot be determined and all avenues of verifying eligibility are exhausted, a private payment agreement must be made before services are rendered.

If proof of eligibility is provided after the patient has paid for services, provider must refund payment to patient and bill Texas Medicaid.

Also if the provider accepts Texas Medicaid but does not participate in the client’s Medicaid Managed Care Plan and the client insists on seeing the provider, the provider can request the Private Pay Agreement to be signed and make the client responsible for the payment.

If a provider limits acceptance of Texas Medicaid patients (without discriminating) a private pay agreement can be used.

Provider may use the Private Pay Agreement to confirm that the client understands the defini-tive office policy and is being accepted as a private pay client.

Providers should continue to update the client’s file reflecting changes in insurance status (this includes Texas Medicaid status).

Note: If the client has been a patient in the past and at that time they had Texas Medicaid, be sure to check eligibility thoroughly and document all steps.

Note: If a service is not a benefit of Texas Medicaid, you do not need a private pay agreement.

When to Use the Client Acknowledgement Statement

When a specific procedure is requested by the client and the provider does not believe the procedure to be medically necessary (even though the service is a benefit of Texas Medicaid). If claim denies for medical necessity, provider must have this statement signed by the client in order to bill the client.

”I understand that, in the opinion of (provider’s name), the services or items that I have requested to be provided to me on (dates of service) may not be covered under the Texas Medical Assistance Program as being reasonable and medically necessary for my care. I un-derstand that the HHSC or its health insuring agent determines the medical necessity of the services or items that I request and receive. I also understand that I am responsible for pay-ment of the services or items I request and receive if these services or items are determined not to be reasonable and medically necessary for my care.”

”Comprendo que, según la opinión del (nombre del proveedor), es posible que Medicaid no cubra los servicios o las provisiones que solicité (fecha del servicio) por no considerarlos razonables ni médicamente necesarios para mi salud. Comprendo que el Departamento de Salud de Texas o su agente de seguros de salud determina la necesidad médica de los servicios o de las provisiones que el cliente solicite o reciba. También comprendo que tengo la responsibilidad de pagar los servicios o provisiones que solicité y que reciba si después se determina que esos servicios y provisiones no son razonables ni médicamente necesarios para mi salud.”



Prior Authorization

Addendum to Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form

Section A: Requested Durable Medical Equipment and Supplies

This section was completed by (check one): □ Requesting Physician □ Supplier

Client name: Client date of birth: / /

Client Medicaid number: Is client under 21 years of age? Yes □ No □

Supplier Information

Name: Telephone: Fax number:

Address:

TPI: NPI:

Taxonomy: Benefit Code:

Prescribing Physician Information

Name: Telephone: Fax number:

I certify that the services being supplied under this order are consistent with the physician's determination of medical necessity and prescription. The prescribed items are appropriate and can safely be used in the client’s home when used as prescribed.

DME/medical supplies provider representative signature: Date: / /

DME/medical supplies provider representative name (Typed or Printed): Item

Number HCPCS Code Description of

DME/medical supplies

Quantity Price Prior authorization

required?

Beyond

quantity limit?1 Custom item?

1

6 □ Y □ N □ Y □ N □ Y □ N 7 □ Y □ N □ Y □ N □ Y □ N 8 □ Y □ N □ Y □ N □ Y □ N 9 □ Y □ N □ Y □ N □ Y □ N

10 □ Y □ N □ Y □ N □ Y □ N 11 □ Y □ N □ Y □ N □ Y □ N 12 □ Y □ N □ Y □ N □ Y □ N 13 □ Y □ N □ Y □ N □ Y □ N 14 □ Y □ N □ Y □ N □ Y □ N 15 □ Y □ N □ Y □ N □ Y □ N 16 □ Y □ N □ Y □ N □ Y □ N 17 □ Y □ N □ Y □ N □ Y □ N 18 □ Y □ N □ Y □ N □ Y □ N 19 □ Y □ N □ Y □ N □ Y □ N 20 □ Y □ N □ Y □ N □ Y □ N 21 □ Y □ N □ Y □ N □ Y □ N 22 □ Y □ N □ Y □ N □ Y □ N 23 □ Y □ N □ Y □ N □ Y □ N 24 □ Y □ N □ Y □ N □ Y □ N 25 □ Y □ N □ Y □ N □ Y □ N 26 □ Y □ N □ Y □ N □ Y □ N

1. If “Yes,” additional documentation must be provided to support determination of medical necessity.

□ Check if additional documentation is attached as outlined in the TMPPM.

Is the DME Provider Medicare certified? YES □ NO □ If yes, indicate Medicare number:

Section B: Diagnosis and Medical Need Information This is a prescription for DME/supplies and must be filled out by the prescribing physician.

By signing this form, I hereby attest that the information completed in Section “A” is consistent with the determination of the client's current medical necessity and prescription. By prescribing the identified DME and/or medical supplies, I certify the prescribed items are appropriate and can safely be used in the client’s home when used as prescribed.

Signature and attestation of prescribing physician: Date: / /

Signature stamps and date stamps are not acceptable

Prescribing physician’s license number:

Prescribing physician’s TPI: Prescribing physician’s NPI:

□ Check if all of the information in Section A was complete at the time of the prescribing provider signature Effective Date_07302007/Revised Date_06012007

Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form See instructions for completing Title XIX Home Health Durable Medical Equipment (DME)/Medical Supplies Physician Order Form. This order form cannot be accepted beyond 90 days from the date of the physician's signature. Fax completed form to 1-512-514-4209.

Section A: Requested Durable Medical Equipment and Supplies This section was completed by (check one): □ Requesting Physician □ Supplier Client name: Client date of birth: / /

Client Medicaid number: Is client under 21 years of age? YES □ NO □

Supplier name: Supplier address: Supplier telephone: Supplier Fax: Supplier TPI: Supplier NPI: Supplier Taxonomy: Supplier Benefit Code: Physician name: Physician telephone: Physician Fax: I certify that the services being supplied under this order are consistent with the physician's determination of medical necessity and prescription. The prescribed items are appropriate and can safely be used in the client’s home when used as prescribed.

DME/medical supplies provider representative signature: Date: / / DME/medical supplies provider representative name (Typed or Printed):

Item Number

HCPCS Code Description of DME/medical

supplies

Quantity Price Prior authorization

required?

Beyond quantity limit?1

Custom item?1

1 □ Y □ N □ Y □ N □ Y □ N

2 □ Y □ N □ Y □ N □ Y □ N

3 □ Y □ N □ Y □ N □ Y □ N

4 □ Y □ N □ Y □ N □ Y □ N

5 □ Y □ N □ Y □ N □ Y □ N

1. If “Yes,” additional documentation must be provided to support determination of medical necessity. □ Check if additional documentation is attached as outlined in the TMPPM. Is the DME Provider Medicare certified? YES □ NO □

If yes, indicate Medicare number:

Section B: Diagnosis and Medical Need Information This is a prescription for DME/supplies and must be filled out by the prescribing physician.

Item Number2

(From Section A)

ICD-9 Brief Diagnosis Descriptor Complete justification for determination of medical necessity for requested item(s)2

(Refer to Section A, footnote 1)

_ _ _ . _ _

_ _ _ . _ _

_ _ _ . _ _

_ _ _ . _ _

2. Each item requested in Section A must have a correlating diagnosis and medical necessity justification. Enter all Item numbers from the table in Section A that pertain to each diagnosis. If applicable, include height/weight, wound stage/dimensions and functional/mobility status in table below. Height Weight Wound stage/dimensions Functionality/mobility status

Note: The "Date last seen" and "Duration of need" items below must be filled in. Date last seen by physician: / /

Duration of need for DME: ____________ month (s) Duration of need for supplies: ____________ month (s)

By signing this form, I hereby attest that the information completed in Section “A” is consistent with the determination of the client's current medical necessity and prescription. By prescribing the identified DME and/or medical supplies, I certify the prescribed items are appropriate and can safely be used in the client’s home when used as prescribed.

Signature and attestation of prescribing physician: Date: / /

Signature stamps and date stamps are not acceptable

Prescribing physician’s license number:

Prescribing physician’s TPI: Prescribing physician’s NPI: □ Check if all of the information in Section A was complete at the time of the prescribing provider signature

Effective Date_10212008/Revised Date_10212008

Note: A PDF version of this form can be accessed by clicking on the “Medicaid Forms” link under “Provider

Forms” on the TMHP website homepage.



CSHCN Services Program – Services Requiring Authorization and Prior Authorization1

Follow the guidelines listed below for services that must be authorized or prior authorized. Additional information is available in the CSHCN Services Program Provider Manual.


Services Requiring Authorization

The following services, equipment, and supplies re-quire authorization. Mail authorization requests with claims.

Blood pressure devices (in specific instances) •Botulinum Toxin (Type A and B) when pro-•vided for diagnoses other than those listed in the manualDiapers, liners, pull-ups, and underpads (or any •combination of these supplies) when in quanti-ties that exceed 300 per monthDME (with the exception of custom, manual, •or powered wheelchairs, custom seating systems, and pediatric hospital cribs and tops)Freestanding ambulatory surgery (not includ-•ing procedures listed above that require prior authorization)Hemophilia supplies and blood factor products•Home health (skilled nursing only) up to 200 •hours per calendar yearHospital ambulatory surgery (outpatient hos-•pital day surgery, not including procedures that require prior authorization)Nebulizers, in specific instances •(See “Nebulizers” in the CSHCN Services Program Provider Manual.)Orthotics and prosthetics•Outpatient dental surgical procedures•Outpatient physical, occupational, and speech •pathology therapiesPrescription shoes•

DSHS-CSHCN Services Program issues authorizations and processes claims for family support services only (see previous page for mailing address). Claims and authorizations for all other services are processed by TMHP.

Services Requiring Prior Authorization

Prior authorization must be obtained before performing, obtaining, or prescribing these services:

Anterior temporal lobectomies•Augmentative communication devices (ACD)•Bone marrow/stem cell transplants (initial and one •subsequent transplant)Certified respiratory care practitioner•Cleft/craniofacial surgical procedures•Cranial molding devices (dynamic orthotic cranioplasty •only)Custom wheelchair (manual or powered) purchases and •custom seating systemsHome health (skilled nursing) services over 200 hours •per calendar yearInpatient admissions•Inpatient admissions extensions•Inpatient rehabilitation admissions•Medical nutritional or services, in specific instances (• See “Medical Nutrition Services” and “Authorzation Require-ments in the CSHCN Services Program Provider Manual.)More than two nutritional assessments per calendar year•More than four nutritional counseling sessions per •calendar yearOrthodontia•Pediatric hospital cribs and tops•Reduction mammoplasties•Renal transplants•Respiratory therapy•Rhizotomies•Select dental procedures (including inpatient admis-•sions for dental surgical procedures)Ultrasonic nebulizers (in specific instances)•Vaccines/toxoids (when the vaccine is not provided by •the Texas Vaccines for Children Program)



CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME) (page 1 of 5) For specialized seating or custom wheelchair purchase requests, also complete the 5-page CSHCN Services Program Wheelchair Seating Evaluation Form. Please print or type requested information below.

Client Information First name: Last name:

CSHCN Services Program number: 9 -00 Date of birth:

Street/City/ZIP: Diagnosis (ICD-9-CM):

Statement of Medical Necessity – Required for ALL equipment requests Item(s) is to be: □ Purchased □ Modified □ Repaired □ Rented and if rental, service date __________________

Client’s height: Client’s weight:

Description of Item:

Equipment needed for: □ Lifetime □ < 6 months □ > 6 months □ > 1 year □ Other ____________________

I certify that the patient’s medical condition is such that all equipment requested above is medically necessary. (Some items may require additional medical justification.) Refer to CSHCN Services Program Provider Manual Chapter 14.2, Reimbursements, page 14-5.

Type or print physician’s name:

Physician’s signature: Date signed:

Equipment Information Must be completed and signed by the vendor. The equipment description and pricing information indicated below must be complete. For manually priced custom DME requests, attach manufacturer’s price sheet(s) for each item.

Equipment Description Pricing Information

Brand Name or

HCPCS Code Model # Item Description Quantity HCPCS Price Cost/Retail

Price CSHCN Services

Program Price

Total

* wheelchair modifications or repairs list the make/model: Serial # DOP:

Provider Information Orthotist/prosthetist name: Signature:

CSHCN TPI: NPI:

Taxonomy code: Benefit code:

Supplier/provider name: CSHCN TPI:

NPI: Taxonomy code: Benefit code:

Telephone number: Fax number:

Address/City/ZIP:

Signature of DME provider: Date:

Page 1 of 5 Effective Date_09082008/Revised Date_09082008

SAMPLE

Note: A PDF version of this form can be accessed by clicking on the “CSHCN Services Program Forms” link

under “Provider Forms” on the TMHP website homepage.



CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME) (page 2 of 5)

This form provides additional lines for requests that contain more than 5 items.

Equipment Description Quantity Information Pricing Information

Brand Name or HCPCS Code

Model # Item Description Quantity Beyond Quantity Limit?

HCPCS Price

Cost/Retail Price

CSHCN Services Program Price

Total

Client Information

First name: Last name:

CSHCN Services Program number: 9- -00



Required for gait trainer and prone or supine stander requests, in addition to page 1.

Client Information



Additional Information for Gait Trainer Requests

Child’s condition/functional level:

Is the child expected to be ambulatory, and if so, when?

Specify the time, frequency, and location where the gait trainer will be used:

Specify the length of time the gait trainer is expected to be needed:

Specify the growth potential of the equipment:

Therapist’s name typed or printed:


Therapist’s signature: Date:

Additional Information for Prone or Supine Stander Requests

Child’s condition/functional level:

Specify anticipated benefits expected from the stander:

Frequency and amount of time of the child’s standing program (e.g., 45 minutes, 3 x daily):

Frequency the stander will be used at home:

Length of time the stander is expected to be needed (growth potential):

Therapist’s name typed or printed:


Therapist’s signature: Date:



Required for car seat or travel restraint, hospital crib/enclosed bed, or electronic hospital bed requests, in addition to page 1.

Client Information



Additional Information for Special Needs Car Seat or Travel Restraint Requests

Head control: □ Good □ Fair □ Poor

Trunk control: □ Good □ Fair □ Poor

Equipment requested:

Name of certified installer:

Name and title of person completing form:

Date: Telephone number:

Additional Information for Hospital Crib/Enclosed Bed Requests

Medical needs, developmental level, and functional skills:

Describe any other less-restrictive devices which have been used, the length of time used, and why ineffective:

Describe why a regular child’s crib, regular bed, or standard hospital bed cannot be used:

Name of therapist or doctor typed or printed:




Additional Information for Electric Hospital Bed Requests Is the client able to assist with his/her personal care and can physically operate the controls? Answer: Yes _____ No ____. If No, please answer the following two questions:

1) Describe why the caretaker is physically limited and cannot crank a manual bed.

2) Describe the medical necessity why the client may require quick adjustment of the bed for medical issues.

Name of therapist or doctor typed or printed:






Required for hygiene equipment requests, in addition to page 1.

Client Information



Additional Information for Hygiene Equipment Requests

Equipment requested:

Length of time needed: Is this replacement equipment? □ Yes □ No

If replacement, why existing equipment cannot be used:

Tone: □ High □ Low □ Fluctuating □ Absent

Head control: □ Good □ Fair □ Poor

Trunk control: □ Good □ Fair □ Poor

Upper extremity: □ Good □ Fair □ Poor

Lower extremity: □ Good □ Fair □ Poor

Transfers: □ Dependent □ Independent






Accessing the TMHP Website and Prior Authorization Submission Form

Access the secure pages of www.tmhp.com. 1.

Click the link, “2. Submit a Prior Authorization.”

Enter your username and password in the popup box. 3.

Texas Medicaid providers who do not have an existing account must setup a provider administrator account to access online claim submission and the other secure functions of the website.

On the first screen, complete the following information.4.

Provider/Supplier ID – : Select the requesting provider or supplier’s valid TPI from the drop-down menu. The menu’s selections are based on the access granted to the user by the provider administrator.

Client ID: – Enter the valid nine-digit client ID for which the prior authorization is being requested.

Authorization Area: – Select the appropriate authorization area for the request. Authorization areas included in the PA system include Home Health, CCP, CCIP, SMPA, Ambulance, and PCCM.

Submission Type: – Select the appropriate submission type for the request.

Requested Authorization Dates: – Use the calendar drop-down function or type in the dates for which you are requesting the authorization.

Click the 5. Next Step button.

When the button is clicked, the system verifies whether the client is eligible for the program on the requested prior authorization dates and checks for duplicate prior authorizations.

On the second screen, verify the information on the next screen that is automatically populated.6.

Complete remaining information. Questions are dynamic and specific to the items requested.7.



Read the Terms and Conditions and acknowledge consent by checking the 8. We Agree checkbox

Certification and Terms and Conditions: Before submitting each prior authorization request, the Provider and Authorization Request submitter must read, understand, and agree to the Certification and Terms and Condi-tions of the prior authorization request.

Submit the Request.9.

Submit the Request: After the We Agree checkbox is checked, the Submit Request button at the bottom of the page becomes enabled. To submit the request to TMHP, click the Submit Request button. After the button has been selected, the prior authorization is checked against a series of validation edits, which confirm that all required fields have been populated.

Once a request is complete and passes all of the validation edits, the prior authorization request is saved, and the user is given a Prior Authorization Number (PAN).



Attachments

Requestors are not able to submit attachments to their online prior authorizations at this time. If it is necessary to send an attachment with a prior authorization request, providers must submit the request and attachments by mail. Providers that send attachments to an authorization that was submitted on the portal must include the prior autho-rization number on the attachments.

Search for an Existing Prior Authorization and Review Status

Users can search for a prior authorization and review prior authorization status on www.tmhp.com. This functional-ity is available for all prior authorizations that are currently in the TMHP system, including PCCM.

Go to www.TMHP.com and click 1. Search/Extend an Existing Prior Authorization.

The next screen gives you two choices: To find an existing authorization request by using a PA number or searching by NPI/API numbers and dates. For this demonstration, we will search using NPI numbers and dates

Click the 2. Or Search for a Request radio button.

Select the provider’s or supplier’s valid NPI from the drop-down menu.3.

Enter the valid nine-digit client ID. 4.

This is an optional field. If this field is not populated, the search is completed for all of the potential clients in the TMHP system.

Use the drop-down calendar function or type in the dates for which you are requesting the prior authoriza-5. tion. The prior authorization date is required in the From field. The prior authorization date is optional for the Through field.

If the Through field is not populated with a date, the search defaults to the current date.

Click the 6. Search button.



A list of prior authorizations that meet the specified criteria is displayed. To view a specific 7. prior authorization, click on the blue, underlined number in the Auth # field.

Each prior authorization will have at least two statuses—the complete status of the entire prior authorization and the status of each detail.

Important: Prior authorization is a condition for reimbursement; it is not a guarantee of payment.

The status can be found in the Status field within the Authorization Information section of the prior authorization being viewed. The complete prior authorization has one of the following four statuses:

In Process:• TMHP has received the prior authorization but is still in the process of re-viewing it. It has not yet been determined whether or not the prior authorization will be approved.

Pending:• TMHP has received the prior authorization, reviewed it, and has determined that more information is necessary before finalizing the status. TMHP staff will contact the requesting provider or supplier by telephone, fax, or mail for additional information.

Approved:• TMHP has approved at least one procedure detail in the prior authorization. Refer to the procedure details section to identify which procedure details have been ap-proved.

Denied:• TMHP has denied the prior authorization request. TMHP has sent the requesting provider or supplier correspondence about the denial by mail or fax.



Verification of Receipt

Effective Date_06/01/2008/Revised Date_08/20/2008

DME Certification and Receipt Form Certificación y Recibo de Equipo Médico Duradero (DME)

(Page 1 of 3—Required) This certification is required by section 32.024 of the Human Resources Code and must be completed before the DME provider can be paid for

durable medical equipment provided to a Medicaid client.

Esta certificación es necesaria bajo la Sección 32.024 del Código de Recursos Humanos y se debe llenar antes de pagarle al proveedor de equipo médico duradero por el equipo entregado al cliente de Medicaid.

Section A: Client Information Name: Medicaid ID Number:Address: City: State: ZIP:Telephone Number: Alternate Telephone Number:

Section B: Provider Information Provider Name: Prior Authorization Number (PAN): NPI/API: TPI:

Section C: Product Information Date of Service:

Procedure Code: Description: Serial No.: Procedure Code: Description: Serial No.: Procedure Code: Description: Serial No.: Procedure Code: Description: Serial No.: Procedure Code: Description: Serial No.:

Section D: Certification

This is to certify that on (month/day/year) _______________________ the client received the __________________________ (equipment) as prescribed by the physician. The equipment has been properly fitted to the client and/or meets the client’s needs.

The client, parent, guardian of the client, and/or caregiver of the client has received training and instruction regarding the equipment’s proper use and maintenance.

________________________________________ ___________________________________________________ Printed name of DME Supplier Printed name of Client, Parent, Guardian, or Primary Caregiver

________________________________________ ___________________________________________________ Signature of DME Supplier Signature of Client, Parent, Guardian, or Primary Caregiver

Section D (Optional) : Certification (Spanish)

Esto certifica que el: (mes/día/año) _________________________ el cliente recibió _____________________________ (equipo) que el doctor recetó. El equipo fue adaptado correctamente para el cliente y satisface sus necesidades.

El cliente, padre, tutor o cuidador principal del cliente recibió entrenamiento e instrucción en el uso y mantenimiento correcto del equipo.

________________________________________ ___________________________________________________ Nombre del proveedor de equipo médico duradero Nombre del cliente, padre, tutor o cuidador principal

________________________________________ ___________________________________________________ Firma del proveedor de equipo médico duradero Firma del cliente, padre, tutor o cuidador principal

This form must be submitted to TMHP for DME products with an allowed amount of $2500 dollars or more. Submit this form with claim form or fax this form to 512-506-6615. Information submitted in this form must match the claim form. This form must be filled out completely; place none or N/A where applicable. Incomplete forms will be returned and will cause a delay in the verification and payment process. Failure to submit this form will affect claim payment.

Notice to Clients: You may be contacted to verify receipt of the equipment provided.

Aviso al cliente: Es posible que lo contactemos para verificar que recibió equipo.

Note: A PDF version of this form can be accessed by clicking on the “Medicaid Forms” link under “Provider Forms” on the TMHP website homepage.





(Page 2 of 3—Required only for requests containing six or more items)

Client Information Medicaid ID Number:

Provider Information Provider Name: Prior Authorization Number (PAN): NPI/API: TPI:

Product Information (Continuation) Date of Service: Procedure Code: Description: Serial No.: Procedure Code: Description: Serial No.: Procedure Code: Description: Serial No.: Procedure Code: Description: Serial No.: Procedure Code: Description: Serial No.: Procedure Code: Description: Serial No.: Procedure Code: Description: Serial No.: Procedure Code: Description: Serial No.: Procedure Code: Description: Serial No.: Procedure Code: Description: Serial No.: Procedure Code: Description: Serial No.: Procedure Code: Description: Serial No.: Procedure Code: Description: Serial No.: Procedure Code: Description: Serial No.: Procedure Code: Description: Serial No.:

Certification

This is to certify that on (month/day/year) _______________________ the client received the __________________________ (equipment) as prescribed by the physician. The equipment has been properly fitted to the client and/or meets the client’s needs.

The client, parent, guardian of the client, and/or caregiver of the client has received training and instruction regarding the equipment’s proper use and maintenance.

________________________________________ ___________________________________________________ Printed name of DME Supplier Printed name of Client, Parent, Guardian, or Primary Caregiver

________________________________________ ___________________________________________________ Signature of DME Supplier Signature of Client, Parent, Guardian, or Primary Caregiver

Certification (Spanish)

Esto certifica que el: (mes/día/año) _________________________ el cliente recibió _____________________________ (equipo) que el doctor recetó. El equipo fue adaptado correctamente para el cliente y satisface sus necesidades.

El cliente, padre, tutor o cuidador principal del cliente recibió entrenamiento e instrucción en el uso y mantenimiento correcto del equipo.

________________________________________ ___________________________________________________ Nombre del proveedor del equipo médico duradero Nombre del cliente, padre, tutor o cuidador principal

________________________________________ ___________________________________________________ Firma del proveedor del equipo médico duradero Firma del cliente, padre, tutor o cuidador principal



(Page 3 of 3—Not for submission to TMHP) High Cost DME Call Verification

Your provider has sent you some medical equipment. We want to make sure that you got what you wanted and that it works well. We need to talk to you about the equipment before we can pay for it.

Call TMHP at 1-888-276-0702. Please call us toll-free at 1-888-276-0702 as soon as you can. We are open Monday through Friday from 8 a.m. to 5 p.m., Central Time. If you call us after hours, you can leave a message. Tell us your name, phone number, and the best time to call you back.

Required Information Please have this information with you when you call: • Name • Medicaid Number • Date of birth • Address (street, city, state, ZIP) • Provider’s name • Date you got the equipment • Details about the equipment

Su proveedor le envió equipo médico. Queremos saber si recibió lo que pidió y si funciona bien. Necesitamos hablar con usted sobre este equipo antes de que paguemos por él.

Llámenos al 1-888-276-0702. Por favor, llámenos gratis lo antes posible al 1-888-276-0702. Nuestras oficinas están abiertas de lunes a viernes, de 8 a.m. a 5 p.m., Hora del Centro. Si nos llama después de estas horas, puede dejar un mensaje con su nombre, número de teléfono y el mejor momento para volver a llamarlo.

Información que necesitamos Cuando llame, tenga esta información a la mano : • Nombre. • Número de Medicaid. • Fecha de nacimiento. • Dirección (calle, ciudad, estado, código postal). • Nombre del proveedor. • Fecha en que recibió el equipo. • Detalles sobre el equipo.



CSHCN Services Program Documentation of Receipt

This form must be kept in the client’s file for all augmentative communication devices, durable medical equipment (DME), eyewear, orthotics and prosthetics, and prescription shoes. Do not submit this form with your claim.

For help completing this form, call the TMHP-CSHCN Services Program Contact Center at 1-800-568-2413 or 1-512-514-3000 and select Option 2.

Please print or type requested information below.

Client Information: First name: Last name:

CSHCN Services Program number: 9- -00 Date of birth:

Address/City/ZIP:

Diagnosis (ICD-9-CM):

Product Information:

Item Number Received

Description (Include Model Number if Applicable)

Manufacturer’s Serial Number (for DME only)

Certification: I certify that on (mm/dd/yyyy):

The client received the product as prescribed by the physician.

The product has been properly fitted to the client and meets the client’s needs.

The client, the parent or guardian of the client, and any caregiver of the client has received training and instruction regarding the proper use and maintenance of the product.

Print or type receiver’s name:

Signature of client, parent or client representative: Date:

Print or type supplier or provider name:

Signature of supplier or provider: Date:

THE RECEIVING PARTY AND THE SUPPLIER MUST SIGN AND DATE THIS FORM AT THE TIME THE PRODUCT IS ACTUALLY RECEIVED OR DELIVERED. THE DATE OF DELIVERY OF THE PRODUCT ON THIS FORM IS THE DATE OF SERVICE THAT SHOULD APPEAR ON THE CLAIM. PROVIDERS MUST MAINTAIN A COPY OF THIS FORM IN THEIR FILES FOR THE LIFE OF THE PRODUCT OR

EQUIPMENT OR UNTIL IT IS AUTHORIZED FOR REPLACEMENT.

Effective Date_10022007/Revised Date_05162008

SAMPLENote: A PDF version of this form can be accessed

by clicking on the “CSHCN Services Program Forms” link under “Provider Forms” on the

TMHP website homepage.



Claims Filing

Filing a Claim

All claims submitted for DME supplies must include the same quantities or units that are doc-umented on the delivery slip or invoice and on the Home Health Services (Title XIX) Durable medical Equipment/Medical Supplies Physician Order form. They must reflect the number of units by which each product is measured. Remember, each product is measured differently.

For example, diapers are measured as individual units. If one package of 300 diapers is deliv-ered, the delivery slip, invoice, and the claim must reflect that 300 diapers were delivered—not one package. Diaper wipes, on the other hand, are measured as boxes/packages. If a box of 200 wipes is delivered, the delivery slip, invoice, and the claim must reflect that one box was deliv-ered instead of 200 individual wipes.

Claim Filing Instructions for TexMedConnect

Go to TMHP.com and click the link, “Access TexMedConnect.”1.

Log into the system by entering your username and password.2.

Select 3. Claims Entry from the navigation panel on the left hand side of the screen.

Select the appropriate billing provider information.4.

A list of NPI/API and related data such as taxonomy, physical address, and benefit code selections is displayed based on the user’s logon information..

Enter the client number for the claim (optional).5.

The system populates most of the required fields on the Client tab.

Note: If you do not enter the client number, you must to enter all required fields manually on the Client tab.

Select the claim type from the drop-down menu.6.



Click 7. Proceed to Step 2.

The Claims Entry screen appears for the selected claim type.

Proceed through each tab and enter claim information.8.

On the “Other Insurance/Submit Claim” tab, select the source of payment. 9.

Read the terms and conditions and check the “10. We Agree” box.

Click 11. Submit.

Click on each individual tab and fill in the information necessary to complete the claim.



Saving a Claim

Claims cannot be submitted until all required information has been entered correctly. The fol-lowing message screen appears if the information has been entered incorrectly.

Error fields are indicated with red exclamation marks.

Once all required fields have been completed, the claim can be submitted by clicking on the last tab, “Other Insurance/Submit Claim.”

At the bottom of the screen, four choices will be available:

Save Draft:• Adds claim to the draft list for completion at a later time.

Save Template:• Adds claim to the template list for quicker claims creation in the future.

Save to Batch:• Adds claim to the pending claims list for batch submission.

Submit:• Submits one claim at a time.

Note: After a claim is submitted, an ICN number is generated.



Advantages of Electronic Services1

It’s fast. No more waiting by the mailbox or phone inquiries; know what’s happening to claims in less than 24 hours and receive reimbursement for approved claims within a week. TexMed-Connect users can submit individual requests interactively and receive a response immediately.

It’s free. All electronic services offered by TMHP are free, including TexMedConnect and its technical support and training.

It’s safe. TMHP EDI services use VPN and SSL connections, just like the United States gov-ernment, banks, and other financial institutions, for maximum security.

It’s accurate. TexMedConnect and most vendor software programs have features that let providers know when they’ve made a mistake, which means fewer rejected and denied claims. Rejected claims are returned with messages that explain what’s wrong, so the claim can be cor-rected and resubmitted right away.

It’s there when it’s needed. Electronic services are available day and night; from home, the of-fice, or anywhere in the world.

It makes record keeping and research easy. Not only can TexMedConnect be used to send and receive claims, it can retrieve Electronic Remittance and Status (ER&S) Reports, perform claim status inquiries, and archive claims. TexMedConnect can generate and print reports on everything it sends, receives, and archives.

It’s reliable. Paper forms can be lost in the mail, the handwriting can be illegible, or the form could have been folded or crumpled during transit. TexMedConnect is always available and, since the information is typed, the data is easily deciphered by the computer, which makes data entry easy and efficient.




1a. INSURED’S I.D. NUMBER (For Program in Item 1)

4. INSURED’S NAME (Last Name, First Name, Middle Initial)

7. INSURED’S ADDRESS (No., Street)

CITY STATE

ZIP CODE TELEPHONE (Include Area Code)

11. INSURED’S POLICY GROUP OR FECA NUMBER

a. INSURED’S DATE OF BIRTH

b. EMPLOYER’S NAME OR SCHOOL NAME

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorizepayment of medical benefits to the undersigned physician or supplier forservices described below.

SEX

F

HEALTH INSURANCE CLAIM FORM

OTHER1. MEDICARE MEDICAID TRICARE CHAMPVA

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary

to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignmentbelow.

SIGNED DATE

ILLNESS (First symptom) ORINJURY (Accident) ORPREGNANCY(LMP)

MM DD YY15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.

GIVE FIRST DATE MM DD YY14. DATE OF CURRENT:

19. RESERVED FOR LOCAL USE

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line)

FromMM DD YY

ToMM DD YY

1

2

3

4

5

625. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT?

(For govt. claims, see back)

31. SIGNATURE OF PHYSICIAN OR SUPPLIERINCLUDING DEGREES OR CREDENTIALS(I certify that the statements on the reverseapply to this bill and are made a part thereof.)

SIGNED DATE

SIGNED

MM DD YY

FROM TO

FROM TO

MM DD YY MM DD YY

MM DD YY MM DD YY

CODE ORIGINAL REF. NO.

$ CHARGES

28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE

$ $ $

PICA PICA

2. PATIENT’S NAME (Last Name, First Name, Middle Initial)

5. PATIENT’S ADDRESS (No., Street)

CITY STATE

ZIP CODE TELEPHONE (Include Area Code)

9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)

a. OTHER INSURED’S POLICY OR GROUP NUMBER

b. OTHER INSURED’S DATE OF BIRTH

c. EMPLOYER’S NAME OR SCHOOL NAME

d. INSURANCE PLAN NAME OR PROGRAM NAME

YES NO

( )

If yes, return to and complete item 9 a-d.

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

20. OUTSIDE LAB? $ CHARGES

22. MEDICAID RESUBMISSION

23. PRIOR AUTHORIZATION NUMBER

MM DD YY

CA

RR

IER

PA

TIE

NT

AN

D IN

SU

RE

D IN

FO

RM

AT

ION

PH

YS

ICIA

N O

R S

UP

PL

IER

INF

OR

MA

TIO

N

M F

YES NO

YES NO

1. 3.

2. 4.

DATE(S) OF SERVICEPLACE OFSERVICE

PROCEDURES, SERVICES, OR SUPPLIES(Explain Unusual Circumstances)

CPT/HCPCS MODIFIER

DIAGNOSISPOINTER

FM

SEXMM DD YY

YES NO

YES NO

YES NO

PLACE (State)

GROUPHEALTH PLAN

FECABLK LUNG

Single Married Other

3. PATIENT’S BIRTH DATE

6. PATIENT RELATIONSHIP TO INSURED

8. PATIENT STATUS

10. IS PATIENT’S CONDITION RELATED TO:

a. EMPLOYMENT? (Current or Previous)

b. AUTO ACCIDENT?

c. OTHER ACCIDENT?

10d. RESERVED FOR LOCAL USE

Employed Student Student

Self Spouse Child Other

(Medicare #) (Medicaid #) (Sponsor’s SSN) (Member ID#) (SSN or ID) (SSN) (ID)

( )

M

SEX

DAYSOR

UNITS

F. H. I. J.24. A. B. C. D. E.

PROVIDER ID. #

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a.

EMGRENDERING

32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH #

NUCC Instruction Manual available at: www.nucc.org

c. INSURANCE PLAN NAME OR PROGRAM NAME

Full-Time Part-Time

17b. NPI

a. b. a. b.

NPI

NPI

NPI

NPI

NPI

NPI

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

G.EPSDTFamilyPlan

ID.QUAL.

NPI NPI

CHAMPUS

( )

1500

APPROVED OMB-0938-0999 FORM CMS-1500 (08/05)

SAMPLE



Tips on Expediting Paper Claims1

Use the following guidelines to enhance the accuracy and timeliness of paper claims processing.

General requirements

Use original claim forms. Don’t use copies of claim forms.•

Detach claims at perforated lines before mailing.•

Use 10 x 13 inch envelopes to mail claims. Don’t fold claim forms, appeals, or correspon-•dence.

Don’t use labels, stickers, or stamps on the claim form.•

Don’t send duplicate copies of information.•

Use 8 ½ x 11 inch paper. Don’t use paper smaller or larger than 8 ½ x 11 inches. •

Don’t mail claims with correspondence for other departments.•

Data Fields

Print claim data within defined boxes on the claim form.•

Use black ink, but not a black marker. Don’t use red ink or highlighters.•

Use all capital letters.•

Print using 10-pitch (12-point) Courier font, 10 point/ Don’t use fonts smaller or larger •than 12 points Don’t use proportional fonts, such as Arial or Times Roman.

Use a laser printer for best results. Don’t use a dot matrix printer, if possible.•

Don’t use dashes or slashes in date fields.•

Attachments

Use paper clips on claims or appeals if they include attachments. Don’t use glue, tape, or •staples.

Place the claim form on top when sending new claim, followed by any medical records or •other attachments.

Number the pages when sending when sending attachments or multiple claims for the •same client (e.g., 1 of 2, 2 or 2).

Don’t total the billed amount on each claim form when submitting multi-page claims for •the same client.

Use the CMS-approved Medicare Remittance Advice Notice printed from the Medicare •Remit Easy Print (MREP) (professional services) or PC-Print (institutional services) when sending a Remittance Advance from Medicare or the paper MRAN received from Medi-care or a Medicare Intermediary. You may also download a TMHP-approved MRAN template from the TMHP website at ww.tmhp.com

Submit claim forms with MRANs and R&S Reports.•

1 Source: 2009 Texas Medicaid Provider Procedures Manual, Section 5.1.6.1



Medicare Crossover Claims1

When a service is a benefit of Medicare and Medicaid, the claims must be filed with Medicare first. Providers should not file a claim with Medicaid until Medicare has dispositioned the claim. The payment received from Medicare and the coinsurance and/or deductible payment from Medicaid must be considered payment in full. Medicaid pays the beneficiary’s Part A and B deductibles and coinsurance liabilities on valid Medicare claims. These guidelines exclude clients living in a nursing facility.

Providers must accept Medicare assignment to received coinsurance and deductible amounts from Medicaid services provided to clients. If a provider has accepted a Medicare assignment, the provider may receive payment of the Medicare deductible and coinsurance from TMHP on behalf of the qualified Medicare beneficiary (QMB) or Medicaid qualified Medicare beneficiary (MQMB) client.

Providers accepting Medicare or Medicaid assignment cannot legally require the client to pay the Medicare coinsurance and/or deductible amounts.

Medicare primary claims filed to Medicare Administrative Contractors (MACs) may be trans-ferred electronically to TMHP through a Coordination of Benefits Contractor (COBC) for claims processed as assigned. Providers should contact their MAC for more information. This benefit allows providers to receive disposition from both carriers while only filing the claim once. Providers allow 60 days from the date of Medicare’s disposition for a claim to be shown on the Medicaid R&S Report. Claims totally denied by Medicare are not automatically trans-ferred to TMHP.

For crossover claims that are not transferred electronically, providers must submit a paper claim to TMHP.

Medicare Crossover Reimbursement of Part B2

The payment of the Medicare Part B coinsurance and deductibles for Texas Medicaid clients who are Medicare beneficiaries is based on the following:

If the Medicaid client is eligible for Medicaid only as a qualified Medicare beneficiary •(QMB), Medicaid pays the Medicare Part B coinsurance/deductible on valid Medicare claims.

If the Medicaid client is not a QMB, Medicaid pays the client’s Part B:•

Deductible liability on valid, assigned Medicare claims.•

Coinsurance liability on valid, assigned Medicare claims that are within the amount, dura-•tion, and scope of Texas Medicaid, and would be covered by Medicaid when the services are provided, if Medicare did not exist. Medicaid payment of a client’s coinsurance/deduct-ible liabilities satisfies the Medicaid obligation to provide coverage for services that Medic-aid would have paid in the absence of Medicare coverage.

1 Source: 2009 Texas Medicaid Provider Procedures Manual, Section 5.12




Clients Eligible for Medicaid and CSHCN Services Program Benefits1

If the Medicaid claims administrator (TMHP) denies a claim with explanation of benefits (EOB) code 182 (client not eligible), but the family has evidence that the client is eligible for Medicaid, providers must appeal or resubmit the claim to TMHP. Client Medicaid eligibility information may not have been available at the time of claim submission.

Medicaid Texas Health Steps-Comprehensive Care Program (THSteps-CCP) and Texas Med-icaid (Title XIX) Home Health Services cover medically necessary services for enrolled clients 20 years of age and younger. The CSHCN Services Program does not consider reimbursement for services provided to children who are also eligible for Medicaid, with the exception of trans-portation of a deceased client’s body.

The CSHCN Services Program does not pay claims for clients eligible for Medicaid THSteps-CCP that are denied by Texas Medicaid for any reason, including: late filing, limited client, duplicate services, incorrect claim form, or additional information required.

For additional information about Medicaid THSteps-CCP, call 1-800-846-7470, is available Monday through Friday, from 7 a.m. to 7 p.m, Central Time.

Information regarding Texas Medicaid is printed on the CSHCN Services Program Eligibility Form. The coverage is indicated by the word Medicaid, below the date of birth in the CSHCN Services Program Client Number block. This information is obtained at the time of the appli-cation, and it must be verified at the time service is provided.

If Medicaid pays benefits that also were paid by the CSHCN Services Program, the full CSHCN Services Program payment must be refunded. Providers must make the refund check payable to TMHP and send it to the attention of the TMHP Financial Unit at the following address:

Texas Medicaid & Healthcare Partnership Attn: Financial Unit, MC-A07

12357-B Riata Trace Parkway, Suite 150 Austin, TX 78727

The following information must be included:

Client name and CSHCN Services Program client number•

Copies of the R&S Reports from both Texas Medicaid and the CSHCN Services Program •showing the claims were paid

Date of service•

Provider name•

Provider identifier numbers•




Filing Deadlines

Texas Medicaid and the CSHCN Services Program share many of the same filing deadlines. The table below shows the most common deadlines.

Medicaid CSHCN Services Program

New Claims: All claims, except where noted in the provider manuals, must be received within 95 days of the date of service. ü üOther Insurance: Claims involving other insurance, including Medicare, must be received within 95 days of the date of disposition. When a service is billed to a third party and no response has been received, providers must allow 110 days to elapse before submitting a claim to TMHP. However, the federal 365-day filing requirement must still be met.

ü ü

Appeals: Appeals must be received within 120 days of the date of the R&S Report on which the denial appears ü ü

For a complete list of filing deadlines and filing deadline exceptions, please refer to the current Texas Medicaid Pro-vider Procedures Manuals and CSHCN Services Program Provider Manual.

Remittance and Status (R&S) Report Example



Electronic Remittance and Status (ER&S) Agreement

Before your ER&S Agreement* can be processed, you MUST choose ONE of the following: * These changes affect ONLY the ELECTRONIC version of the Remittance & Status Report. To make

changes to the PAPER version of the R&S report, contact TMHP Provider Enrollment.

Set up INITIALLY (first time). Use Production User ID*: (9 digits)

CHANGE Production User ID FROM: (9 digits)

TO: (9 digits)

REMOVE Production ID Remove: (9 digits)

** The TMHP Production User ID (Submitter ID) is the electronic mailbox ID used for downloading your Electronic Remittance & Status (ER&S) reports. For assistance with identifying and using your Production User ID and password, contact your software vendor or clearinghouse.

This information MUST be completed before your request can be processed.

Provider Name (must match TPI/NPI number) Billing TPI Number Provider Tax ID Number

Provider’s Physical Address Billing NPI Number Provider Phone Number

Provider Contact Name (if other than provider) Provider Contact Title Contact Phone Number

Do not complete this block UNLESS the ER&S will be downloaded by anyone OTHER than the provider.

Name of Business Organization to Receive ER&S Business Organization Phone Number

Business Organization Contact Name Business Organization Contact Phone No.

Business Organization Address Business Organization Tax ID

Check each box after reading and understanding the following statements. If you are unsure about anything that is stated below, contact the TMHP EDI Help Desk at (888) 863-3638. All three statements must be checked before we can process your Electronic Remittance & Status Agreement.

I (we) request to receive Electronic Remittance and Status information and authorize the information to be deposited in the electronic mailbox as indicated above. I (we) accept financial responsibility for costs associated with receipt of Electronic R&S information.

I (we) understand that paper formatted R&S information will continue to be sent to my (our) accounting address as maintained at TMHP until I (we) submit an Electronic R&S Certification Request form.

I (we) will continue to maintain the confidentiality of records and other information relating to recipients in accordance with applicable state and federal laws, rules, and regulations.

Provider Signature Date

Title Fax Number

DO NOT WRITE IN THIS AREA — For Office Use

Input By: Input Date: Mailbox ID: Effective Date_07302007/Revised Date_06012007

— A STATE MEDICAID CONTRACTOR Page 1 of 2 ERSAG05/2007 v1.1

Note: A PDF version of this form can be accessed by clicking on the “Medicaid Forms” link under “Provider Forms” on the TMHP website

homepage.



Appeals

Appeal Methods

An appeal is a request for reconsideration of a previous-ly dispositioned claim. Providers may use three methods to appeal Medicaid claims to TMHP:

Electronic•

Automated Inquiry System (AIS)•

Paper•

TMHP must receive all appeals of denied claims and requests for adjustments on paid claims within 120 days from the date of disposition of the Remittance and Sta-tus (R&S) Report on which that claim appears. If the 120-day appeal deadline falls on a weekend or holiday, the deadline is extended to the next business day.

Standard administrative requests and medical appeals must be sent first to TMHP or the claims process-ing entity as a first-level appeal. After the provider has exhausted all aspects of the appeals process for the entire claim, the provider may submit a second-level appeal to HHSC.

A first-level appeal is a provider’s initial standard 1. administrative or medical appeal of a claim that has been denied or adjusted by TMHP. This appeal is submitted by the provider directly to TMHP for adjudication and must contain all required infor-mation to be considered. Detailed instructions are found in the program provider manual (2009 Texas Medicaid Provider Procedures Manual, Section 6.1; 2008 CSHCN Services Program Provider Manual, Section 7.1)

A second-level appeal is a provider’s final medical or 2. standard administrative appeal to HHSC of a claim that meets all of the following requirements:

It has been denied or adjusted by TMHP.a.

It has been appealed as a first-level appeal to b. TMHP.

It has been denied again for the same reason(s) c. by TMHP.

This appeal is submitted by the provider to HHSC, which may subsequently require TMHP to gather information related to the original claim and the first-level appeal. HHSC is the sole adjudicator of this final appeal.

All providers must submit second-level administrative appeals and exceptions to the 95-day filing deadline ap-peals to the following addresses:

Texas Health and Human Services Commission HHSC Claims Administrator Contract Management

Mail Code 91X PO BOX 204077

Austin, Texas 78720-4077

CSHCN Services Program Administrative Review

Purchased Health Services Unit, MC-1938 Texas Department of State Health Services

PO Box 149347 Austin, TX 78714-9347



Electronic Appeals

Claims with a finalized status can be appealed directly from TexMedConnect. To appeal a claim, follow these steps:

Click 1. Appeals in the left navigation panel.

Note: The user must have appropriate security rights to access this section.

Enter the claim number you want to appeal.2.

If you do not know the claim number, enter information about the claim and click 3. Search.

If a match is found, the CSI Search Details screen will appear.

Click Appeal Claim to continue the appeal process.4.

Most fields populate with the claim information. You can modify the claim information 5. for the appeals.



Automated Inquiry System Appeals1



The following appeals may be submitted using AIS:

Client Eligibility:• The client’s correct Medicaid number, name, and date of birth are required.

Provider Information (Excluding Medicare •Crossovers): The correct provider identifier is re-quired for the billing provider, performing provider, referring provider, and limited provider. The name and address of the provider are required for the facility and outside laboratory.

Claim Corrections:• Providers may correct the fol-lowing:

Patient control number (PCN) –

Date of birth –

Date of onset –

X-ray date –

Place of service (POS) –

Quantity billed –

Prior authorization number (PAN) –

Beginning date of service –

Ending date of service –

The following appeals may not be appealed through AIS:

Claims listed on the R&S Report as Incomplete •Claims

Claims listed on the R&S Report with $0 allowed •and $0 paid

Claims requiring supporting documentation (for •example, operative report, medical records, home health, hearing aid, and dental X-rays)

DRG assignment•

Procedure code, modifier, or diagnosis code•

Medicare crossovers•

Claims listed as pending or in process with EOPS •messages

Claims denied as past filing deadline except when •retroactive eligibility deadlines apply

Claims denied as past the payment deadline•

Inpatient Hospital claims requiring supporting •documentation

Third-party resource (TPR)/Other insurance•

Providers may appeal these denials either electronically or on paper.

Refer to:“Disallowed Electronic Appeals” on page 6-2 of the 2009 Texas Medicaid Provider Procedures Manual to determine if these appeals can be billed electronically. If these appeals cannot be billed electronically, a paper claim must be submitted.

Automated Inquiry System Automated Appeals Guide2

To access the AIS automated appeals guide, providers can call 1-800-925-9126 (1-800-568-2413 for CSHCN Ser-vices Program). Providers may submit up to three fields per claim and 15 appeals per call. If during any step invalid information is entered three times, the call transfers to the TMHP Contact Center for assistance.



Paper Appeals1

After determining a claim cannot be appealed electronically or through AIS, appeal the claim on paper by completing the following steps:

Copy the R&S page where the claim is paid or denied. A copy of other official notification 1. from TMHP may also be submitted.

Circle one claim per R&S page in black or blue ink.2.

Identify the reason for the appeal.3.

If applicable, indicate the incorrect information on the claim, and provide the corrected 4. information that should be used to appeal it.

Attach a copy of any supporting medical documentation that is required or has been re-5. quested by TMHP.

Attach a completed claim form.6.

Reminder:Do not copy supporting documentation on the opposite side of the R&S Report.

Note: It is strongly recommended that providers submitting paper appeals retain a copy of the documentation being sent. It also is recommended that paper documentation be sent by certified mail with a return receipt requested. This documentation, along with a detailed listing of the claims en-closed, provides proof that the claims were received by TMHP, which is particularly important if it is necessary to prove that the 120-day appeals deadline has been met. If a certified receipt is provided as proof, the certified receipt number must be indicated on the detailed listing along with the Medicaid number, billed amount, DOS, and a signed claim copy. The provider may need to keep such proof regarding multiple claims submissions if the provider identifier is pending.

Medicare crossovers and inpatient hospital appeals related to medical necessity denials or DRG assignment/adjustment must be submitted on paper with the appropriate documentation.

Submit correspondence, adjustments, and appeals (including routine inpatient hospital claims) to the following address:

Texas Medicaid & Healthcare Partnership Appeals/Adjustments

PO Box 200645 Austin, TX 78720-0645




Waste, Abuse, and Fraud

Definitions

Waste:• Practices that allow careless spending and/or inefficient use of resources.

Abuse:• Practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary program cost, or in reimbursement for services that are not medi-cally necessary or do not meet professionally recognized standards for health care.

Fraud:• An intentional deceit or misrepresentation made by a person with the knowledge that deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable federal or state law.

Most Frequently Identified Fraudulent Practices

Billing for services not performed.•

Billing for unnecessary services.•

Upcoding or unsubstantiated diagnosis.•

Billing outpatient services as inpatient services.•

Over Treating/lack of medical necessity.•

Identifying Waste, Abuse, and Fraud

The Health and Human Services Commission (HHSC), Office of Inspector General (OIG) is responsible for investigating waste, fraud, and abuse in all Health and Human Services (HHS) programs. OIG’s mission is to protect the:

Integrity of health and human services programs in Texas.•

Health and welfare of the recipients in those programs.•

OIG oversees HHS activities, providers, and recipients through compliance and enforcement activities designed to:

Identify and reduce waste, abuse, fraud, or misconduct.•

Improve efficiency and effectiveness through the HHS system.•



OIG is required to set up clear objectives, priorities, and performance standards that help:

Coordinate investigative efforts to aggressively recover Medicaid overpayments.•

Allocate resources to cases with the strongest supportive evidence, and the greatest poten-•tial for recovery of money.

Maximize the opportunities to refer cases to the Office of Attorney General.•

Human Resources code, Chapter 32 Medical Assistance Program (Medicaid), §32.039

(a) (4) A person “should know” or “should have known” information to be false if the person acts in deliberate ignorance of the truth or falsity of the information or in reckless disregard of the truth or falsity of the information, and proof of the person’s specific intent to defraud is not required.

When reporting waste, abuse, or fraud, gather as much information as you can.

Examples of provider information include:

Name, address, and phone number of the provider.•

Name and address of the facility (hospital, nursing home, and home health agency, etc.).•

Medicaid number of the provider and facility is helpful.•

Type of provider (physician, physical therapist, and pharmacist, etc.).•

Names and numbers of other witnesses who can aid in the investigation.•

Copies of any documentation you can provide (examples: records, bills, and memos).•

Dates of occurrences.•

Summary of what happened—include an explanation along with specific details of the •suspected waste, abuse, or fraud. For example: Dr. John Doe requires employees to bill for extra quantities or bill higher level of service than actually provided.

Names of recipients for which services are questionable.•

Examples of recipient information include:

The person’s name.•

The person’s date of birth and Social Security number, if available.•

The city where the person resides.•

Specific details about the fraud—such as “Jane Doe failed to report her husband, John •Doe, lives with her and he works at ABC Construction in Anyplace, TX.”

Reporting Waste, Abuse, and Fraud1

Individuals with knowledge about suspected Medicaid waste, abuse, or fraud of provider ser-vices must report the information to the HHSC OIG. To report waste, abuse, or fraud, go to www.hhsc.state.tx.us and select Report Waste, Abuse, and Fraud. Individuals may also call the OIG hotline at 1-800-436-6184 to report waste, abuse, or fraud if they do not have access to the Internet.




Resources

Instructions for Using the TMHP Website

The TMHP website at www.tmhp.com, was designed to streamline provider participation. Through the website, provid-ers can submit claims and appeals, download provider manuals and bulletins, verify client eligibility, view Remittance and Status (R&S) and panel reports, and stay informed with current news and updates. Current news remains on the TMHP website homepage for ten business days and is then moved to the news archive (available from the News Archive link on the left hand side of the main page).

Searching the TMHP Website

Some providers may find it easier to search the TMHP website using the site’s search function rather than navigating through the news and archive sections. To use the search feature, providers must type the desired keywords into the search box located in the upper right-hand corner of the homepage, and click the green arrow or press Enter. To improve search results, providers should use logical operators (and, or, and not) or enclose search phrases in quotation marks. When phrases are enclosed in quotation marks, the search feature returns only those pages that contain the exact phrase, rather than returning the pages that contain any of the words in the phrase.

In addition to the site’s search feature, providers can use popular search engines, such as Google™, to easily find information ap-plicable to their provider type. To use Google to search only the TMHP website, follow these steps:

From an internet browser (Internet Explorer, Firefox, etc.), 1. go to www.google.com.

In the search box, type “site:www.tmhp.com” followed by 2. the keyword(s) for the search (see example).

Click 3. Google Search.

Google displays a list of all the pages on the TMHP website that contain the keyword(s).

Providers can use Google’s advanced search (available by clicking the Advanced Search link) to filter their results by date, language,



and file format. For example, providers can choose to display only those pages updated within the past three months. Providers can also exclude certain words or phrases from their results or specify where on the page the desired term should appear (for example, in the title of the page or in the body of the page).

Functions

On the TMHP.com website, you’ll be able to:

Enroll as a provider into our system to •access the many benefits available.

Use TexMedConnect to file a claim •electronically, reducing errors and speeding up the reimbursement of funds.

Review and print out our documents, •peruse our user guides, and search through the library for previous work-shop materials.

Register for a workshop and view up-•coming events.

View the status of a submitted prior •authorization.

Submit an authorization.•

Immediately verify the eligibility of a •client.



Information

On the TMHP.com website, you’ll find:

Provider Manuals and Guides:

Texas Medicaid Provider Procedures Manual•

CSHCN Services Program Provider Manual•

Texas Medicaid Quick Reference Guide•

CMS-1500 Online Claims Submission Manual•

2008 Automated Inquiry System User Guide-•Medicaid

2008 Automated Inquiry System User Guide-•CSHCN

TexMedConnect instructions for Acute Care and •Long Term Care

Provider Forms:

Medicaid Forms•

CSHCN Services Program Form•

Enrollment Forms•

Bulletins and Banner Messages:

Medicaid Bulletins•

CSHCN Bulletins•

Banner Messages•

Software, Fee Schedules, Reference Codes:

Fee Schedules•

Acute Care Reference Codes•

LTC Programs Reference Codes•



TMHP Telephone and Fax Communication

Contact Telephone/Fax Number

TMHP Contact Center (general information)Automated Inquiry System (AIS)

1-800-925-9126 or 1-512-335-5986

Provider Enrollment Fax 1-512-514-4214

Comprehensive Care Program (CCP) (CCP prior authorization status and general CCP and Home Health Services information)

1-800-846-7470 (voice)1-512-514-4211 (fax)

Children with Special Health Care Needs (CSHCN) Services Program AIS 1-800-568-2413

CSHCN Services Program Fax 1-512-514-4222

Comprehensive Care Inpatient Psychiatric (CCIP) Unit (prior authorization and general informa-tion)

1-800-213-8877 (voice)1-512-514-4211 (fax)

Home Health Services (includes durable medical equipment [DME]):Option 1 – TMHP in-home care customer service Option 2 – DME supplier with completed Title XIX form Option 3 – Registered nurse (RN) with completed plan of care (POC)

1-800-925-8957 (voice)1-512-514-4209 (fax)

Health Insurance Premium Payment (HIPP) 1-800-440-0493

Long Term Care (LTC) Operations 1-800-626-4117

LTC—Nursing Facilities 1-800-727-5436

Telephone Appeals 1-800-745-4452

TMHP Electronic Data Interchange (EDI) Help Desk 1-888-863-3638

TMHP EDI Help Desk Fax 1-512-514-4228 1-512-514-4230

Texas Health Steps (THSteps) Dental Inquiries 1-800-568-2460

THSteps Medical Inquiries 1-800-757-5691

Third Party Resources (TPR) (Option 2) 1-800-846-7307

TPR Fax 1-512-514-4225

Medicaid Audit/Cost Reports 1-512-506-6117

Medicaid Audit Fax 1-512-506-7811

Family Planning (Tubal Ligation/Vasectomy Consent Forms) Fax 1-512-514-4229

Hysterectomy Acknowledgment Statements Fax 1-512-514-4218

CSHCN Services Program Telephone and Fax Communication

Contact Telephone/Fax Number

TMHP-CSHCN Prior Authorization and Authorization Fax 1-512-514-4222

Provider Enrollment Fax 1-512-514-4214

Provider Enrollment Phone 1-800-568-2413, Option 2

CSHCN Services Program Customer Service Phone 1-800-252-8023

TMHP Electronic Data Interchange (EDI) Help Desk 1-888-863-3638

TMHP EDI Help Desk Fax 1-512-514-4228

Third-Party Resource (TPR) Phone 1-800-846-7307

TPR Fax 1-512-514-4225

CSHCN Services Program Complaints Unit Fax 1-800-441-5133

Appeal Submission through AIS Line 1-800-568-2413



Written Communication With TMHP

All CMS-1500 forms (excluding ambulance, radiology/laboratory, immunization services, rural health, and mental health rehabilitation) sent to TMHP for the first time, as well as claims being resubmitted because they were initially denied as incomplete claims, must be sent to the following address:

Texas Medicaid & Healthcare Partnership Claims

PO Box 200555 Austin, TX 78720-0555

The post office box addresses must be used for the specific items listed in the following table:

Correspondence Address

Appeals/adjustments of claims (except zero paid/zero al-lowed on Remittance & Status [R&S] Reports) Electronically rejected claims past the 95-day filing deadline and within 120 days of electronic rejection report

Texas Medicaid & Healthcare Partnership Appeals/Adjustments PO Box 200645 Austin, TX 78720-0645

All first-time claims Texas Medicaid & Healthcare Partnership Claims PO Box 200555 Austin, TX 78720-0555

Ambulance/CCP requests (prior authorization and appeals) Texas Medicaid & Healthcare Partnership Comprehensive Care Program (CCP) PO Box 200735 Austin, TX 78720-0735

CSHCN Services Program claims Texas Medicaid & Healthcare Partnership CSHCN Services Program Claims PO Box 200855 Austin, TX 78720-0735

Dental prior authorization requests Texas Medicaid & Healthcare Partnership Dental Prior Authorization PO Box 202917 Austin, TX 78720-2917

Home Health Services prior authorizations Texas Medicaid & Healthcare Partnership Home Health Services PO Box 202977 Austin, TX 78720-2977

Medicaid audit correspondence Texas Medicaid & Healthcare Partnership Medicaid Audit PO Box 200345 Austin, TX 78720-0345

Medical necessity forms 3652, 3618, and 3619, and purpose code E information

Texas Medicaid & Healthcare Partnership Long Term Care—Nursing Facilities PO Box 200765 Austin, TX 78720-0765

Medically Needy Clearinghouse (MNC) or Spend Down Unit correspondence

Texas Medicaid & Healthcare Partnership Medically Needy Clearinghouse PO Box 202947 Austin, TX 78720-2947

Provider Enrollment correspondence Texas Medicaid & Healthcare Partnership Provider Enrollment PO Box 200795 Austin, TX 78720-0795




Other provider correspondence Texas Medicaid & Healthcare Partnership Provider Relations PO Box 202978 Austin, TX 78720-0978

Send all other written communication to TMHP Texas Medicaid & Healthcare Partnership (Department) 12357-B Riata Trace Parkway, Suite 150 Austin, TX 78727

TPR/Tort correspondence Texas Medicaid & Healthcare Partnership Third Party Resources/Tort PO Box 202948 Austin, TX 78720-2948

Provider Enrollment Contract/Credentialing Texas Medicaid & Healthcare Partnership PCCM Contracting/Credentialing PO Box 200795 Austin, TX 78720-4270

Written Communication with CSHCN Services Program


First-Time Claims (Resubmit all “Zero Allowed, Zero Paid” claims. Resubmit claims originally denied as an “Incomplete Claim” on an R&S Report)

Texas Medicaid & Healthcare Partnership Attn: CSHCN Services Program Claims PO Box 200855 Austin, TX 78720-0855

Appeals and Adjustments Texas Medicaid & Healthcare Partnership Attn: CSHCN Services Program Appeals, MC-A11 12357-B Riata Trace Parkway, Suite 150 Austin, TX 78727

Provider Complaints CSHCN Services Program ATTN: Complaints Purchased Health Services Unit, MC-1938 Texas Department of State Health Services PO Box 149347 Austin, TX 78714-9347

Prior Authorization and Authorization Texas Medicaid & Healthcare Partnership Attn: TMHP-CSHCN Services Program Authorizations Depart-ment, MC-A11 12357-B Riata Trace Parkway, Suite 150 Austin, TX 78727

Enrollment Texas Medicaid & Healthcare Partnership Attn: Provider Enrollment PO Box 200795 Austin, TX 78720-0795

Third-Party Resource Texas Medicaid & Healthcare Partnership Third-Party Resource Unit PO Box 202948 Austin, TX 78720-9981

Electronic Claims and Rejected Reports (Past the 95-day filing deadline)

Texas Medicaid & Healthcare Partnership PO Box 200645 Austin, TX 78720-0645

Other Correspondence (Must be directed to a specific department or individual)

Texas Medicaid & Healthcare Partnership Attn: CSHCN Services Program Appeals, MC-A11 12357-B Riata Trace Parkway, Suite 150 Austin, TX 78727



EOB Codes - Top Reasons for Claim Denial

Home Health DME

00103:• Services exceed allowed benefit limitations.

00075:• Missing, invalid, or future dates of service.

00565:• Received past 95 day filing deadline .

Medical Supplier DME

00565:• Received past 95 day filing deadline.

00260:• Client is covered by other insurance which must be billed prior to this program.

00144:• This procedure not covered for this provider type.

Medical Supply Company

00100:• A charge was not noted for this service.


00260:• Client is covered by other insurance which must be billed prior to this program.

Custom DME


00164:• These services are not in accordance with Medical Policy.

00572:• It is mandatory that authorization be obtained. Due to lack of approval, the service is nonpayable.

You can find a current list of the commonly occuring EOB codes fore each provider type on our website. Go to www.thmp.com and click on EOB at the top of the page.



Common Claim Denial Codes

00103 - Services exceed allowed benefit limitations:• Client has exhausted benefits for the service billed.

00075 - Missing, invalid, or future dates of service:• Claim was submitted without dates of service, incomplete information for the dates of service, or future dates of service.

00100 - A charge was not noted for this service:• Billed amount was either not submitted on the claim or was invalid.

00143 - Client not Eligible:• The client ID was included on the claim; however, the client does not have Medic-aid eligibility for that DOS or the client associated with that ID had Medicaid either before or after the DOS.

00144 - This procedure not covered for this provider type:• Procedure code submitted is not billable for the billing provider.

00164 -These services are not in accordance with Medical Policy:• Services billed fall outside of the medical policy guidelines for the program billed.

00260 - Client is covered by other insurance which must be billed prior to this program:• Medicaid is the method of last resort. Any other insurance providers must be billed before Medicaid has been. This includes Medicare Part A coverage

00265 - Client is Medicare Part B Eligible:• Your client is eligible for Medicare Part B for the DOS and the service is covered by Medicare Part B, but the claim was not submitted to Medicaid as a crossover with a Medi-care EOB attached. In some cases, your claim crossed over directly from Medicare but Medicare denied the line because of an error on the claim that was originally submitted to Medicare.

00266 - QMB Client Eligible for Medicare Crossovers Only:• Qualified Medicare Beneficiary (QMB) – MEDICAID covers the co-insurance and deductible on MEDICARE covered services only after MEDICARE has paid. If service is not covered by Medicare, MEDICAID WILL NOT PAY

00424 - Billing Provider Not Enrolled on DOS:• The billing provider’s Medicaid enrollment status is not ac-tive.

00345 - Claim Exceeds Filing Time Period:• The claim was submitted after 120 days from the first DOS with no proof of timely filing attached.

00565 - Received past the 95 day filing deadline:• The claim was submitted after 95 days from the first DOS with no proof of timely filing attached

00572 - It is mandatory that authorization be obtained. Due to lack of approval, the service is nonpay-•able: The provider did not request authorization for the service billed, the authorization was not on file at the time the service was billed, or the authorization for service billed was denied.

01361 - Exact Duplicate:• Payment has already been made for this claim. This often occurs when a claim is re-submitted before the original claim has been paid. The original submission pays and the subsequent submission denies as a duplicate. This also happens when a provider attempts to adjust or correct an incorrectly paid claim by simply resubmitting the corrected claim.



Acronyms

Acronym Term

AAP American Academy of Pediatrics

ACD Augmentative Communicative Device

ACIP Advisory Committee on Immunization Practices

AMA American Medical Association

ANSI American National Standards Institute

APN Advanced Practice Nurse

BCBS Blue Cross Blue Shield

BiPAP Bi-level Positive Airway Pressure

CAPD Continuous Ambulatory Peritoneal Dialysis

CCP Comprehensive Care Program

CHAMPUS Civilian Health and Medical Program of the Uniformed Services—now called TriCare

CHIP Children’s Health Insurance Program

CMS Centers for Medicare & Medicaid Services (formerly HCFA)

CPAP Continuous Positive Airway Pressure

CSHCN Children with Special Health Care Needs

CSI Claim Status Inquiry

DADS Department of Aging and Disability Services

DARS Department of Assistive and Rehabilitative Services

DME Durable Medical Equipment

DO Doctor of Osteopathy

DOB Date of Birth

DOS Date of Service

DPM Doctor of Podiatric Medicine

DRG Diagnosis-Related Group

DSHS Department of State Health Services

EDI Electronic Data Interchange

EFT Electronic Funds Transfer

EOB Explanation of Benefits

EOPS Explanation of Pending Status

ER&S Electronic Remittance and Status Report

EV Eligibility Verification

FSS Family Support Services

HASC Hospital-based Ambulatory Surgical Center

HCPCS Healthcare Common Procedure Coding System

HHA Home Health Agency

HHSC Health and Human Services Commission

HIC Health Insurance Claim

HIPAA Health Insurance Portability and Accountability Act

HMO Health Maintenance Organization

ICD-9-CM International Classification of Diseases, Ninth Revision, Clinical Modification



ICN Internal Control Number (as in 24-digit ICN)

IPPA Insurance Premium Payment Assistance

IPPB Intermittent Positive Pressure Breathing

IPV Intrapulmonary Percussive Ventilation

JRA Juvenile Rheumatoid Arthritis

LCSW Licensed Clinical Social Worker

LMSW Licensed Master Social Worker

LPC Licensed Professional Counselor

MCO Managed Care Organization

MD Doctor of Medicine

MMIS Medicaid Management Information System

MNP Medically Needy Program

MRN Medicare Remittance Notice

MSRP Manufacturer’s Suggested Retail Price

MTP Medical Transportation Program

NDC National Drug Code

NPI National Provider Identifier

OI Other Insurance

OT Occupational Therapy,

PACT Program for Amplification for Children of Texas

PAF Physician/Dentist Assessment Form

PAN Prior Authorization Number

PCCM Primary Care Case Management

PCN Patient Control Number

POC Plan of Care

POS Place of Service

PPO Preferred Provider Organization

PT Physical Therapy

R&S Remittance and Status Report

RHC Rural Health Clinic

SSL Secure Socket Layer

TAC Texas Administrative Code

TANF Temporary Assistance to Needy Families (formerly AFDC)

TENS Transcutaneous Electric Nerve Stimulator

TMHP Texas Medicaid & Healthcare Partnership

TMPPM Texas Medicaid Provider Procedures Manual

TOS Type of Service

TPI Texas Provider Identifier

TPN Total Parenteral Nutrition (i.e., Hyperalimentation)

TPR Third-Party Resources

UB-04 Uniform Bill 04 CMS-1450

VDP Vendor Drug Program

VPN Virtual Private Networking

WHP Women’s Health Program



Provider Enrollment

Medicaid Enrollment

Providers can enroll online via TMHP.com or may print out the enrollment forms and fax/mail them to TMHP. The next few pages will outline the steps to locate the online registration sec-tion and also where to access the enrollment forms:

Online Enrollment Procedures

Access the Internet and go to TMHP.com.1.

Click the link, 2. Activate my Account.

On the following screen select “New Texas Medicaid Provider.”3.

The following screen will appear. Follow the instructions listed at the top and click the 4. Next button.

The next screen will change based on the selection made here. Since we chose Provider Enrollment (without an NPI/TPI), the following screen is displayed.



Complete the following fields and check the box, “I agree to these terms.”5.

Note: Fields marked with a red asterisk are required.

Click the 6. Create Provider Administrator button.

Shortly after you click the button, you will receive an email at the address provided. This email with contain a copy of your username and password. In addition, it will contain a link back to the TMHP.com site.

CSHCN Services Program Enrollment1

To enroll in the CSHCN Services Program, DME providers must be actively enrolled in Texas Medicaid, have a valid CSHCN Services Program Provider Agreement, have completed the CSHCN Services Program enrollment process, and comply with all applicable state laws and requirements.

Out-of-state DME (noncustom DME) providers must meet all these conditions, and be located in the United States, within 50 miles of the Texas state border, and approved by the De-partment of State Health Services (DSHS).

Important: CSHCN Services Program providers are responsible for knowing, understanding, and complying with the laws, administrative rules, and policies of the CSHCN Services Program and Texas Medicaid. By enrolling in the CSHCN Services Program, providers are charged not only with knowledge of the adopted CSHCN Services Program agency rules published in Title 25 of the Texas Administrative Code (TAC), but also with knowledge of the adopted Medicaid agency rules published in Title 1 of the TAC, Part 15, and specifically including the fraud and abuse provisions contained in Chapter 371.




Custom DME Requirements

Providers who wish to enroll with the CSHCN Services Program as customized DME provid-ers must complete the CSHCN Services Program Provider Enrollment Application as specified in Section 3.1, “Provider Enrollment,” of the CSHCN Program Provider Manual.

Additionally, applicants must either provide evidence of having current certification from the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) as an assistive technology supplier (ATS) and/or assistive technology practitioner (ATP), or provide three separate letters of recommendation from practicing OTs or PTs serving a pediatric popu-lation. These letters must include the name, address, and telephone number of the recommend-ing therapist, place of therapist’s employment, and number of years the therapist has worked with the specific custom DME applicant in providing custom DME. The CSHCN Services Program requires that the letters of recommendation be made by PTs or OTs not employed by the applicant nor receiving any form of compensation for the letters of recommendation.

Providers must send the completed documentation to:

Texas Medicaid & Health Partnership Attn: Provider Enrollment

PO Box 200795 Austin, TX 78720–0795

1-800-291-3734

Additional information and provider enrollment forms are available on the TMHP website at www.tmhp.com.



Notes

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The DME Workshop Participant Guide is produced by TMHP Organizational Development Services. This is intended for educational purposes in conjunction with the DME Workshop Series. Providers should consult the Texas Medicaid Provider

Procedures Manual, CSHCN Services Program Provider Manual, bulletins, and banner messages for updates.

Participant Guide - TMHP Workshop/2009_DME...DME Workshop Participant Guide Services for Children If...

Documents

Transcript of Participant Guide - TMHP Workshop/2009_DME...DME Workshop Participant Guide Services for Children If...